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1

Maslow's Hierarchy of Needs

(basic to complex)

-Physiologic (food, shelter, water, sleep, oxygen, sexual expression)

-Safety

-Love and Belonging

-Esteem and Recognition

-Self-Actualization

2

Nursing Process

ADPIE

Assessment
Diagnosis (Analysis)
Plan
Implementation
Evaluation

3

Tort

An act of involving injury or damage to another resulting in civil liability (i.e. victim can sue) instead of criminal liability.

4

Negligence

-Form of unintentional Tort
-Performing an act that a reasonable and prudent person would not perform

5

Malpractice

-Form of unintentional Tort
-Negligence by professional personnel that RESULTS IN INJURY

4 elements necessary:
Duty: obligation to use due care
Breach of Duty: failure to perform according to standard
Injury/Damages: failure to meet standard of care resulting in physical or mental injury or damage to client
Causation: A connection exists between conduct and resulting injury

6

Intentional Torts

-Assault (mental or physical threat)
-Battery (actual and intentional touching)
-Invasion of privacy (false imprisonment, exposure of a patient, defamation)
-Fraud

7

Surgical Permit

Written
Voluntary
Informed (explained to the client)

8

Informed Consent

-Possible complications, risks, disfigurements
-Removal of any organs or parts of the body
-Benefits and expected results

9

Consent for minors

Children 14-years-old must agree to procedure along with parent/guardian

10

HIPAA

Health Insurance Portability and Accountability Act of 1996
-patient privacy
-non-compliance can result in civil and criminal liability

11

Good Samaritan Act

Protects nurse when providing emergency care

12

LEADERSHIP STYLES

Democratic
Authoritarian
Laissez-faire

Democratic (parcipative): Assertive

Authoritarian (autocratic): Aggressive

Laissez-faire (permissive): Passive

13

5 Rights of Delegation

Right:
Task
Circumstance
Person
Direction/Communication
Supervision

14

Lewin's Change Theory

(Nurse Leaders/Managers as Change Agents)

Unfreezing- Initiation of a change
Moving- Motivation towards a change
Refreezing- Implementation of a change

15

4 Core Competencies for Interprofessional Collaborative Practice

1. values/ethics for interprofessional practice
2. roles/responsibilities
3. interprofessional communication
4. teams and teamwork

16

Ebola

-Risk in US low ,even when working in West African communities.
-Direct contact with blood or bodily fluids
-Contagious after symptoms start (fever, severe headache, muscle pain, diarrhea, vomit, unexplained bleeding).
-21 day isolation
-Full PPE

17

Zika Virus

-Microcehpaly in babies of mothers with Zika
-Remains in blood of infected person for 1 week

18

Disaster Biologic/Chemical/Radiation Agents

Biologic agents:
Anthrax, Pneumonic Plague, Botulism, Smallpox, Inhalation tularemia, Viral hemorrhagic fever

Chemical agents:
Biotoxin agents (ricin)
Nerve agents (sarin)

Radiation

19

Acute Respiratory Distress Syndrome
(ARDS)

-Unexpected, catastrophic pulmonary complication occurring in a person with no previous pulmonary problems. Morality rate ~50% (higher with hx or etoh).
-Characterized by hypoxemia (even on 100% oxygenation), decreased pulmonary compliance, dyspnea, non-cardiac-associated bilateral pulmonary edema, dense pulmonary infiltrates on radiography

-Interventions: Elevate HOB 30 degrees, assist with daily awakening, implement comprehensive oral hygiene program, implement a comprehensive mobilization program.

20

What PaO2 value indicates respiratory failure in adults?

PaO2 <60 mm Hg

21

What blood value indicates hypercapnia?

PCO2 >45 mm Hg

22

Respiratory failure symptoms

-Dyspnea, hyperpnea, crackles (rales), wheezing, decreased breath sounds
-intercostal or substernal retractions
-cyanosis, pallor, molted skin
-increasing diminished breath sounds
-diffuse pulmonary infiltrates on chest radiography (white-out appearance)
-verbalized anxiety, restlessness, confusion, agitation

23

Shock

-Widespread, serious reduction of tissue perfusion (lack of O2 and nutrients)
-Early signs= agitation and restlessness from cerebral hypoxia

Types: Hypovolemic (most common, early/severe below), Cardiogenic, Distributive, Obstructive.

EARLY: tachycardia, hypotension, weak periph pulses, restlessness/agitation/confusion, pale cool clammy skin, decreased urine output (<30 mL/hr)

SEVERE: organ dysfunction, renal failure, pleural effusion, resp distress... renal failure and/or death.

24

Disseminated Intravascular Coagulation (DIC)

In disseminated intravascular coagulation, abnormal clumps of thickened blood (clots) form inside blood vessels. These abnormal clots use up the blood's clotting factors, which can lead to massive bleeding in other places.

Prolonged PT, PTT
Decreased platelets
Increased FSPs

Obvious signs of bleeding, such as hematuria, hematoma at venipuncture sites, hemorrhage in conjunctiva, petichiae.

Treatment: Heparin

25

HELLP Syndrome

(hemolysis, elevated liver enzymes, low platelet count)

-Usually develops before the 37th week of pregnancy but can occur shortly after delivery. Many women are diagnosed with preeclampsia beforehand.

Symptom Triad:
Headache
Nausea/Vomit
URQ/Abd pain (distended liver)

-Treatment usually requires delivery of the baby, even if the baby is premature.

26

Resuscitation (emergency)

Adults /Children: CAB
Chest compressions, airway, breathing)

Newborns : ABC
Airway, breathing, chest compressions

100 compressions/min
2 in/5 cm deep

1 rescuer: 30:2 (for all)
2 rescuers: children/neonate 15:2

27

Cardiac arrest on bedside monitor?

Defibrillation

28

1st drug in hospital for cardiac arrest?

Epinephrine

Also for anaphylactic rxns and severe asthma

29

-Chocking child or infant procedure?
-"blind sweep" of mouth in children or infants?

-Child: subdiaphragmatic abdominal thrusts (Heimlich maneuver) until object expelled or pt unresponsive.
-Infant: repeat cycle of 5 back blows (slaps), 5 chest compressions until expelled or unresponsive.

-NEVER! The object might be pushed farther down into the throat. Only go in if object can be seen.

30

Fluid volume deficit

-H2O and electrolytes can be lost isotonically (serum levels would remain normal)
-Dehydration
-oliguria (concentrated urine), weight loss, postural hyptension, weak/rapid pulse, decreased skin turgor, dry mucous membranes
-Elevated BUN and creatinine, increased osmolarity, elevated Hgb/Hct

31

Fluid volume excess

-H2O and electrolytes can be retained isotonically
-Water intoxication; retain water and Na decreases
-HF, RF, Cirrhosis, excess NaCl ingestion, over-hydration with Na-containing fluid, poorly controlled IV therapy.
-Attention loss, confusion, aphasia, altered LOC
-Decreased BUN, Decreased Hgb/Hct, Decresed serum osmolality, Decreased urine osmolality and specific gravity
-JVD and peripheral edema

32

BUN

Blood urea nitrogen is a medical test that measures the amount of urea nitrogen found in blood. The liver produces urea in the urea cycle as a waste product of the digestion of protein.
-Directly r/t metabolic function of the liver and excretory function of the kidneys

33

Creatinine

-Chemical waste product from muscle metabolism, which fluctuates very little.
-Kidney function (GFR)
-Affected very little by dehydration, malnutrition, or hepatic function... better test for renal function than BUN.

34

erythropoietin (EPO)
What is it?

How to admin if exogenous.

Hormone manufactured by kidneys.
-promotes the formation of red blood cells by the bone marrow.
-damaged kidney= less EPO=reduced oxygen

Exogenous:
IV or SUBQ
HYPERTENSION MAJOR ADVERSE EFFECT! Contraindicated.
Take BP beforehand

Initiated when HGB <10 to alleviate sx of anemia and ned for blood transfusions.

D/C therapy or reduce dose for HGB >11 to prevent thromboembolism.

35

Standard precautions

-Wash hands, even if gloves have been worn
-Wear gloves for touching blood or bodily fluids or any non-intact body surface
-Wear gowns during any procedure that may produce splashes (ex. change client with diarrhea)
-Masks and eye protection during any activity that might disperse droplets (suctioning)
-Do not recap needles, dispose in puncture-resistant container
-Use mouthpiece for resuscitation efforts

36

CD4 T-cell count r/t HIV

CD4 T-cell count:
describes # of infection-fighting lymphocytes a person has

HIV infection destroys CD4 T-cells ad invades them and replicates

Low <750/mm3 for infants
Low <500/mm3 kids 1-5
<200 kids>5/adults
<15% severely immunocompromised

37

HIV

transmission: blood and bodily fluids (unprotected sex, sharing needles, infected blood products, breast milk, needle stick)

Universal precaution: protection from blood and bodily fluids is the goal. Initiate barrier protection b/w caregiver and client (hand washing, gloves, gowns/masks, eye protection)

Labs: Confirm with Western blot test
ELISA can have false-positives

38

PQRSTU

PAIN

Provokes (what makes it worse/better?)

Quality (dull, aching, sharp, stabbing, burning)

Region (where and does it radiate anywhere?)

Severity (pain scale)

Timing (how long, how often, and when?)

Understanding (what do they think causing pain)

39

5 stages of grief

Denial
Anger
Bargaining
Depression
Acceptance

40

Ginger

Treatment of nausea

41

Garlic

decreases hyperlipidemia
*no known interaction with statin medications*

Also anti-platelet. Stop taking before surgery

42

Ginseng

erectile dysfunction, reduce fatigue, enhance mental performance

43

St. John's Wort

Treats depression

Do not mix with other antidepressants (SSRI's and tricyclic antidepressants)

44

Hydration

-thins out mucus trapped in bronchioles and alveoli- facilitates exporation
-essential for client experiencing a fever
- 300-400 mL fluid lost in lungs daily through exporation

45

Increased temps cause...

increase in metabolism and demand for oxygen. Fever also causes dehydration because of excess fluid loss (diaphoresis)

46

Blue bloater

Chronic bronchitis

Use of accessory muscles to breath
Leads to RSHF (cor pulmonale)
Bilateral pedal edema
JVD

47

Pink puffer

Pulmonary emphysema

"floppy" alveoli
increased CO2 retention (pink)
pursed lip breathing (prolonged expiration)
barrel chest from chest overinflation
unproductive cough
tripod position
hyper-resonance upon lung auscultation
thin in appearance
leads to RSHF (cor pulmonale)

48

COPD

Chronic Obstructive Pulmonary Disease

Chronic bronchitis (blue bloater) and pulmonary emphysema (pink puffer)

***Tobacco
***Occupational exposure to chemicals and just (Carbon monoxide, coal, biomass fuels)

NOT FACTORS:
alcohol, poor nutrition, being overweight

Too much inspired oxygen (NC, mask, etc) can decrease drive to breathe

-Report S/S infection (fever, increased sputum, worsening dyspnea)
-Get Flu and pneumococcal vaccine
-Use albuterol, ipratropium if SOB emergency
-eat frequent, small, high calorie meals because of increased energy/work for breathing
--too full puts pressure on diaphragm

-May lead to polycythemia (increase RBCs). Body trying to compensate for chronic hypoxia.

49

ABC vs CAB

ABC-prioritize nursing actions

CAB- during CPR

50

Tuberculosis Dx and Meds

TB test (mantoux) 10mm or greater in diameter 48-72 hrs after test

If (+) and Asymptomatic-might be latent (cannot transmit). Will have normal CXR and neg sputum culture.
NO CORTICOSTEROIDS for latentTB! (prednisone).
Might convert to active TB

Meds: RIPE
*Rifampin/Rifapentine
-Red/orange discoloration of body fluids/tissues
---could perm discolor dentures and contact lenses
-Reduces effectiveness of contraceptives
-Take with meals
-Hepatotoxicity (have liver function test each month)
*Isoniazid
*Pyrazinamide
*Ethambutol

51

Intracellular and Extracellular ions

Intracellular: Potassium and Phosphate

Extracellular: Sodium and Chloride

52

uremia

a raised level in the blood of urea and other nitrogenous waste compounds that are normally eliminated by the kidneys.

Protein should be restricted in CRF clients

GFR used as protein consumption indicator

53

Acute vs Chronic Renal Failure

Acute: often reversible, abrupt deterioration of kidney function

Chronic: irreversible, slow deterioration of kidney function AEB increased BUN and creatinine. Dialysis eventually required

54

Acute Renal Failure Types and Phases

Phases:
*Oliguric- Decreased Output! Pt in FVE, K increases because not excreting urine=HYPERKALEMIC
*Diuretic- Increased Output! Pf in FVD (potential shock), excreting a lot of K=HYPOKALMIC
Recovery-

Types:
*Prerenal- interference with renal perfusion
*Intrarenal- damage to renal parenchyma
*Postrenal- obstruction in urinary tract from the tubules to the urethral meatus

55

Digoxin

-Increases strength and contractility of the heart.
-Increases CO
-Increases Kidney perfusion
*Decreases HR (Hold if HR <60 bpm)
--Apical pulse for 60 seconds
*Excreted through kidney, MEASURE KIDNEY FUNCTION (BUN, creatinine)
-Hypokalemia can lead to toxicity

Normal level: 0.5-2 ng/mL

Used in: a-fib (controls arrhythmia), CHF

Toxicity:
Early: anorexia, nausea, vomit
Late: arrhythmia and vision changes (halo of light or anything else)

56

Nitroglycerin

causes dilation of coronary arteries allowing more oxygen to heart muscle

used for chest pain (1 every 5 min for 15 min)

-Call EMS if unchanged or worse 5 min after first dose

-Treats stable angina

-Stored away from light and heat in original container

-replace every 6 months after opening

57

Atropine

increases heart rate by blocking vagal stimulation (suppresses HR)
Treats brady!

58

Myocardial infarction med admin

MONA
morphine, oxygen, nitroglycerin, aspirin

59

Abdominal Aortic Aneurism
What is it?
S/S?

-An enlargement of the abdominal aorta
-life-threatening if it bursts.
-common in older men and smokers.
-grows slowly, without symptoms.
-Progress: some people may notice a pulsating feeling near the navel. PAIN IN THE BACK, belly, or side may be signs of impending rupture.

60

Thrombophlebitis

A condition in which a blood clot in a vein causes inflammation and pain.

61

Sodium warfarin

Coumadin
Takes 48-72 hrs to take effect. Overlap with heparin common
PT (Prothrombin time) 10-12 sec
INR: 2-3
Antidote- Vitamin K

Uses:
A fib to prevent clots and reduce stroke risk, DVT, PE, Mechanical heart valves (prevent clots on valves)

Contraindicated in pregnancy

62

Heparin

aPTT 30-45 sec
Antidote- protamine sulfate

63

APGAR Score

Appearance
Pulses
Grimace
Activity
Reflex/Irritability

0=absent
1=decreased
2=strongly positive

7 and above= normal
4-6=fairly low
3 and below= critically low

64

Umbilical cord

AVA
2 arteries
1 vein

65

Maternal hypotension intervention

Stop pitocin
Turn on left side
Admin oxygen
If hypovolemia, push IV fluids

66

Antianemica

increase RCB production

67

Anticholinergic Side Effects

BLOCK ACETYLCHOLINE

Hot as a Hare
Dry as a Bone
Blind as a Bat
Red as a Beet
Mad as a Hatter (confusion)

68

Antidiarrheals

Decreases gastric motility and reduce water in bowel

69

Miotics

Constrict pupils

70

Mydriatics

dilates pupils

71

Rule of nines

Body surface area for burns

Head: 9%
Arms: 18% (9% each)
Back: 18%
Legs: 36% (18% each)
Genitalia: 1%

72

Aluminum Hydroxide

Amphojel

GERD and kidney stones
Watch out for constipation

73

Hydroxyzine

Vistrail

Anxiety and itching
Watch out for dry mouth

74

Midazolam

Versed
Conscious sedation

Watch out for resp depression and hypotension

75

Dopamine

Treats symptomatic hypotension, shock, low cardiac output.
Monitor for arrhythmias and BP

76

CPR on pregnant woman

Chest compressions slightly higher on sternum

Displace uterus (might be crushing vena cava) by placing towels/wedge under right hip

77

Postpartum vaginal bleeding

Saturating 1 perineal pad <1 hr is excessive

boggy fundus= uterine atony, full bladder keeps uterus from contracting (make sure bladder empty)

Oxytocin- uterotonic if fundus massage fails

78

Diabetes Insipidus

decrease ADH made (or distributed from) hypothalamus

-increase in thirst likely (polydipsia)
-high serum osmolality
-low urine specific gravity
-weight loss
-possible dehydration

treatment: desmopressin acetate

79

Duchenne's MD

-frequent trips/falls at home
-places hands on thighs to push up to stand (Gower Sign/Maneuver)
-walks on tip toes and has disproportionately large calves
-progressive replacement of muscle tissue with connective tissue

80

glipizide

Type 2 diabetes treatment
oral sulfonylurea for blood sugar

81

levofloxacin

antibiotic
Other drugs/supplements canbind 98% of drug

Take 2 hrs post other meds/supps

82

Potassium chloride usually given with?

usually given with diuretic to prevent hypokalemia

83

heparin flush

usually 2-3 mL of 10 or 100 units/mL vials

84

Foods for Calcium, Vit D, and both

Calcium: cheese, ice cream, greens, almonds, soy, tofu

Vitamin D: tuna, oily fish, cod liver oil, egg yolks

BOTH: milk, yogurt, salmon, cereal

85

Suction Artificial Airway

-hyperoxygenate beforehand
-suction no more than 10-15 seconds
-wait at least 1-2 min between passes
-medium suction pressure for adults 100-120 mm Hg

86

Normal Troponins

Trop I <0.5
Trop T <0.1
increased for MI

87

Management of Cystic Fibrosis

Resp/Diet

Autosomal recessive
Thickened mucus and plugged ducts

RESPIRATORY:
-frequent respiratory/sinus infections
--blood-streaked sputum (hemoptysis) as result of damaged blood vessels common
--priority if pt has 90% O2 on RA
-Chest physiotherapy performed AFTER bronchodilators and nebs
-potential pneumothorax

DIET:
-pancreatic deficiency leads to decreased absorption of fat-soluble vits (ADEK)
-pancreatic enzymes on ALL food (burning if touches lips, make sure on food)
-need INCREASED CALORIC DIET (high protein, high fat)
--difficulty maintaining weight and growth
-fecal retention common..may have steatorrhea (fatty and frothy)

MISC:
-infertility

88

Scopolamine

-anticholinergic to prevent nausea/vomit with motion sickness
-behind ear (dry, hairless)
-4 hours before travel
-replace 72 hrs

89

Depression med directions

DO NOT combine use of SSRI (-pram) with MAOI (-ine).
-Risk of seratonin syndrome
-do not start SSRI until 14 days after stopping MAOI

90

INR

2-3
Risk of bleeding increases as INR rises.
If INR high, DO NOT ADMINISTER ANTICOAGULANT (warfarin)

91

Ventricular Tach on monitor
1st action?

CHECK PULSE
VT with and without pulse possible.

With Pulse: check for clinical stability and O2 sat
Stable? antiarrythmic meds
Unstable (AMS, shock, hypotension, CP, acute HF)? synchronized cardioversion

Without Pulse: CPR/Defib

92

Oxytocin Infusion

-Assess uterine contraction pattern
-Monitor I and O
-Place IV oxytocin in electronic infusion pump
-Connect to secondary line that's attached to the mainline in the PROXIMAL port. Prevents bolus and allows for sudden stop of infusion.
-Continuous electronic FHR monitoring

93

Post-op Chest Tube

Alert HCP if drainage:
>3mL/kg/hr for 3 consecutive hrs
OR
>5-10 mL/kg for 1 hr

Potential hemorrhage or cardiac tamponade

94

Hypothermia post op?

Normal

95

Infant I and O

1-2 mL/kg/hr

96

isosorbide

-Actions identical to nitroglycerine
-decreases cardiac workload by reducing preload and afterload
-Can cause hypotension from vasodilation
-Hold when systolic BP <90
(kidneys trouble with profusion at 80 mmHg)

97

Basal Long-Acting Insulin

Glargine (Lantus)
Detemir

Once Daily
Works up to 24 hrs
Onset: 1-1.5 hrs

98

Intermediate-Acting Insulin

NPH (Humulin N/Novolin N)

***CLOUDY (draw clear before cloudy)
***2x daily
Onset: 1.5-4 hrs
Duration: 12-18 hrs

99

Short-Acting Insulin

Regular (R) Insulin
***Best for IV (DKA)

Onset: 30min-1 hr
Peak: 2-4 hrs
Duration: 8 hrs

100

Rapid-Acting Insulin

Lispro, Aspart, Glulisine
***Best for post-meal hyperglycemia


Onset: <15 min
Peak: 1-2 hrs
Duration: 4-6 hrs

101

Burns

Burn injuries cause cellular destruction, capillary leaking, and fluid shifts (emergent phase 24-72 hrs)


Fluids are lost during the emergent phase (first 24-72 hours), resulting in hypovolemia and hyponatremia. The blood becomes more viscous and increased hematocrit and hemoglobin values result. Cellular damage releases potassium, which causes hyperkalemia.

102

Halo external fixation device

cleaning- chlorahexadine or water
Keep vest liner clean/dry
Foam inserts under pressure points
Small pillow when supine
Keep correct-sized wrench for emergencies

DO NOT: touch device frame when positioning patients
adjust pins (HCP only)

103

Hypothermia:
The client is being rewarmed with blankets, and the IV fluids are being changed over to warmed fluids.
What additional intervention is a priority?

Attach cardiac monitor

After, get additional large bore IV and cover clients head to reduce heat loss (core takes priority over extremities)

104

Bulimia nervosa

Binge eating followed by vomiting, excessive exercise, use of laxatives.
Usually normal or just-above-normal weight.

Anorexia-
severe weight loss
bulky clothing to hide excessive weight loss.

105

Electroconvulsion Therapy

-induces generalized seizure, d/c any anti-convulsant medication
-helps treat mood disorders (major depression and bipolar) and schizophrenia

About:
NPO 6-8 hrs, driving not permitted during treatment, temporary memory loss/confusion immediate side effect, anesthesia used during procedure

106

EpiPen

Inject mid-outer thigh through clothing, hold there for 10 seconds

107

Bipolar Mania

Hyperactivity
Auditory hallucinations
Risk-taking behaviors

108

Lithium Toxicity

Normal: 0.6-1.2
>1.5 = toxicity

Risk factors:
-dehydration (1-2 L water daily)
-decreased renal function (elderly)
-diet low in sodium (YAY FOR SALT!)
-drug-drug interaction (NO NSAIDS and thiazide diuretics)
***acetaminophen for pain relief

Acute: GI symtoms
Chronic: Neuro symptoms

109

Licorice Root

-herb for GI disorders
-when used with diuretics such as HCTZ, increased POTASSIUM LOSS
-risk for hypokalemia

-Pts using diuretics mostly include those with heart disease and/or hypertension

110

PPV

Positive Pressure Ventilation
-increased pressure/expansion in lungs compresses thoracic vessels
-decreased venous return, ventricular preload, and cardiac output = HYPOTENSION
-worse with hypovolemia and decreased venous tone (neuro or septic shock)

111

Necrotizing Enterocolitis

Pre-term infants
Life threatening
Underdeveloped intestines/gut immunity
Frequent abdominal girth measurements
Supine and undiapered
Avoid rectal temps (perforation)

112

Acute diarrhea
(Pediatric)

-Oral rehydration therapy (even if vomiting)
-Avoid BRAT diet
-Assess frequency/amount of wet diapers, fluid intake, sunken eyes
-Protect perineal skin breakdown using skin barrier cream

113

Uterine Rupture

-Vaginal Birth After Cesarian (VBAC) at higher risk
-1st: abnormal FHR pattern (fetal decel & brady)
***constant pain, loss of fetal station, sudden stop of contractions

Unrecognized UR: hemorrhage, hypovolemic, shock, maternal tachy

114

Nephrotic Syndrome
What is it?
Who does it affect?
Treatment

AID
Affects kids 2-7
-proteinuria
hypoalbuminemia (--fluid shift)
-edema (eye, periph, ascites)
-hyperlipidemia

Treatment:
-Corticosteroids/immunosuppressants
-Loss of appetite management (make foods fun/attractive)
-Infection prevention (limit social interaction)
-Low sodium diet while remission
-fluid restriction in severe edema
-recurrence rate high. Parent's need to check protein in urine daily, weight weekly. Record results!

115

Latex allergy

lip swelling from bananas, kiwis, tomatoes, peaches, grapes or avocados
latex balloons

Or rash/Itching 3-4 days after exposure to latex product

116

Isotretinoin

-Nodulistic Acne

It's derived from vitamin A, so don't take extra!

Priority: 2 forms birth control!

More info:
-increased ICP risk
-AVOID tetracycline
-photosensitivity (sunscreen)
-blood donations discouraged
-don't break capsules
-dryness of eyes and mouth and skin common.
-not for prig's (teratogenic)

117

Using a Cane (regular and on Stairs)

Should be held on strong side!
Ex. R-sided stroke = weak left side=hold in R hand

UP: strong leg, cane, weak leg

DOWN: cane, weak leg, strong leg

Pt with total knee replacement can usually bear full weight by time of discharge

118

Placenta Previa

-Abnormal implantation of placenta. Covers cervical os (opening)

*Painless vaginal bleeding >20 wks
-increased r/f hemorrhage

RN: electronic fetal monitoring
pad counts
draw a type and screen
large-bore IV

DO NOT: vaginal/digital exam (even for dilation)

119

Long term corticosteroid therapy

Hydrocortisone
Primary drug for Addison's disease

-never stop abruptly
-notify HCP for s/s of infection
-monitor blood glucose closely if diabetic

-increase dose in times of stress
-osteoporosis
-muscle weakness
-catracts
-GI upset (take with food)

DIET: high calcium (1500mg) high protein (1.5g/kg)
Low fat, low simple CHO

120

Brachytherapy

Internal radiation via implant

-30 min total time near pt during shift
-dosimeter film badge required
-no pregos or <18 near pt
-6 feet distance for all staff
-door closed and radioactive sign outside
-private room/bathroom
-bedrest to prevent dislodgment of implant (24-72 hrs)
-shield with lead with physical contact

121

Anesthesia Pre-op Question

"Has anyone in your family had a bad reaction to anesthesia?"

MALIGNANT HYPERTHERMIA
***muscle stiffness***
***hypercapnia***
***hyperthermia***

-rare, life-threatening INHERITED muscle abnormality
-succinylcholine inhalation at start of anesthesia

-increases Ca release in muscles
--rigidity, increased O2 demand, increased temp

S/S: tachypnea, tachycardia, rigid jaw (general rigidity). Progresses to increased fever

IV dantrolene is reversal agent! Slows metabolism
Also cool client and treat hyperkalemia

122

WBC count

4,000-11,000

123

Chemotherapy Safety

-Low WBC (<4,000) likely
-Reverse/Protective Isolation (pt wears mask)
-Private room
--HEPA filtration or Pos Pressure

AVOID: raw fruits/veggies, standing water, undercooked meat, HCP's with a cold

Lowest WBC count (nadir) 7-10 days after initiation

124

Endotracheal Suction

-sterile
-hyperoxygenate beforehand
-intermittent suctioning during withdrawal only, 10 seconds
-4 or 5 recover breaths or 1-2 min b/w passes

125

Antiplatelet medications

prasugel (Effient)
clopidogrel (Plavix)
ticagrelor (Brilintal)

post coronary intervention

STOP 5-7 DAYS BEFORE SURGERY
Also stop NSAIDS (aspirin, ibuprofen, naproxen, celecoxib)
-Prolong bleeding time

Concerns:
Ginkgo biloba
Peptic ulcer disease
Bleeding disorders
Active bleeding
IC hemorrhage

126

IBS diet

Well tolerated foods: protein, breads, bland foods
-increase fiber intake as tolerated (whole grains, nuts, legumes, fruits, veggies)

AVOID: GI irritants.
Gassy foods (bagels, bananas, cabbage, onions), alcohol, caffeine, spicy foods, dairy, fatty foods

127

IBD exacerbation
and
sulfasalazine Rx

Sulfasalazine topical GI anti-inflammatory and immunomodulatory agent.

-Dehydration risk of IBD.
-Sulfa crystalizes in kidneys if dehydrated.
-Yellow-orange discoloration of skin and urine normal for med.
-Photosensitivity
-Folic acid deficiency

PRIORITY FOLLOW-UP:
Urine specific graviey of 1.035
Normal: 1.003-1.030

IBD: increased erythrocyte sedimentation rate, WBC, and c-reactive protein normal.
Mild anemia normal for chronic inflammatory conditions.

128

SBAR

Situation
Background
Assessment
Recommendation/Request

129

Uterine Infection

Postpartum Endometritis

foul-smelling lochia
fever
chills
tachycardia
uterine tenderness

Serum lab draw for blood culture and sensitivity needed prior to antibiotic administration

130

Constipation

Common- pregos and pts taking ferrous sulfate (iron) supps

High fiber diet (nuts, seeds, fruits, veggies)
High fluid intake
Regular exercise
Bulk-forming fiber supplements
Avoid caffeine (b/c it's a diuretic)

131

Otitis media

infants and kids <2

Often follows respiratory infection such as flu or RSV

Risk factors:
Tobacco exposure
Regular pacifier use (after 6mo)
Drinking from bottle while lying down
Lack immunizations (pneumococcal series)

132

Otitis externa

excess water in ears from bathing or swimming

"Swimmers ear"

Damage due to foreign body in ear also increases risk

133

Neuro Assessment Needed if...

Nuchal rigidity (stiff neck, won't bend down)
-meningitis

Fixed dilated pupils:
-increased ICP
Normal: 3-5mm

New limb drift- stroke


NORMAL ASSESS:
positive doll's eye (oculocephalic reflex)
-intact brainstem

Absent adult Babinski reflex
-toes point down w/ stimulation on sole for negative.
Normal to fan toes (+ reflex) in infants up to 1 yr.

134

Tetralogy of Fallot (TOF)

4 defects: Ventricular Septal defect, Stenotic Pulmonary Valve, Overriding Aorta (from R/L V's), Right Ventricular Hypertrophy

-Cyanotic cardiac defect
-Infants w/ TOF normally maintain O2Sat of 64-85% until surgically corrected

-Increased HGB (polycythemia) result of compensation for hypoxia. DANGEROUS b/c increases blood viscosity.
-Stroke or thromoembolism
-Must stay hydrated

Knee-to-chest position to relieve pain.

Normal Infant HGB:
12.5-20.4

135

Rapid Response Team

HR <40 or >130
SBP <90
Resp rate <8 or >28
O2Sat <90 w/ oxygen
Urine output <50 mL/4hrs
LOC change for 10 min

136

Glascow Coma Scale
(GCS)

High number is good!
Highest= 15
-Eye opening response (1-4)
-Verbal Response (1-5)
-Motor Response (1-6)

15- normal
13-14 mild
9-12 moderate head injury
<8 severe
"WHEN YOU ARE 8, YOU INTUBATE"
3 deep coma or brain death

137

ADHD

3 core sx:
hyperactivity
impulsiveness
inattention

Other:
-impaired social skills
-low self-esteem
-increased risk for depression, anxiety, learning disability, substance abuse
-academic or work failure

138

Tension pneumothorax

-progressive build up of air in pleural space
-d/t lung laceration
- no more pressure holding lungs in place, everything pulled to the opposite side!

TRACHEAL DEVIATION!
-emergency large bore needle decompression followed by chest tube placement to relieve pressure on mediastinal structures

139

Somatic Symptom Disorder (SSD)

psych disorder
stress related
unexplained physical sx

RN: redirect somatic complains to unrelated neutral topics
-limit time discussing physical symptoms

-recognize secondary gains (increased attention, freedom from responsibilities)
-recognize factors that intensify sx (stress)
-incorporate coping strategies

140

Black cohosh

Herbal supp
Menopausal hot flashes

Side effects: thickening of uterine lining, liver toxicity

141

Post cataract surgery

AVOID anything that increases intraoccular pressure:
-bending
-lifting >5 lbs
-sneezing/coughing
-rubbing eye
-straining during BM

Normal: itching, photophobia, mild pain several days post-op

142

Misoprostol

-Synthetic prostaglandin
-protects against gastric ulcers by decreasing stomach acid and increasing mucus production
-usually prescribed to pts on long-term NSAID therapy to avoid ulcers

143

Hepatic Encephalopathy

-temporary worstenig of brain function in ppl with
end-stage liver disease

-inadequate detox of ammonia from blood

Sx:
-factor hepaticus (must, sweet breath)
-lethargy
-confusion
-slurred speech
-coma
-asterixis (flapping tremor)
-constipation (need 2 BM's daily on lactulose)

144

Bacterial meningitis

Most critical intervention: start antibiotic therapy!

Initiate sz precautions IF necessary, but still start therapy first.

Cause will be determined by LP and blood cultures

Complications: hearing loss, permanent brain damage, etc.

145

Monoamine oxidase inhibitors (MAOIs)

Antidepressants

common: isocarboxazid, phenelzine, tranylcypromine

-increased risk for SI
-avoid tyramine containing foods (cheese, overripe fruit, liquor, fermented foods) can cause hypertensive crisis
-sleep dysfunction
-nausea/constipation

146

Collect Sputum Speciment

1. rinse mouth with water
2. wit on side of bed
3. inhale deeply several times
4. cough deeply to raise enough sputum (4-10mL)
5. expectorate into STERILE specimen container

147

mal de ojo

"Evil Eye"
Latin American
-caused by stranger admires child
-kids vomit, fever, cry
-"cure" by admirer touching the child while speaking to the child or immedately afterwards

148

Rheumatoid arthritis
morning stiffness and pain reduction

Take warm shower or bath upon waking.

Heat decreases stiffness and promotes muscle relaxation and mobility

-ROM exercises daily to maintain joint flexibility
-Moist heat packs to stiff joints
-Ice packs to painful joints
-Frequent rest
-Sleep in flat, neutral position to keep joints straight

149

Codeine adverse effects

-constipation (drink 8 glasses water, increase fiber, laxatives if needed)
-nausea/vomiting (take meds with food)
-orthostatic hypotension (sit at side of bed before standing)
-dizziness

150

Higher Suicide Risk

SAD PERSONS

Sex (men>women)
Age (teens, young adults)
Depression (hopelessness)

Prior attempt
Ethanol/drug use
Rational thinking loss (hearing voices)
Support system loss (living alone)
Organized plan
No significant other
Sickness (terminal)

151

Phlebostatic Axis

4th IC space, mid-axillary line (close to V6)

Used as reference for placement of transducer when measuring continuous arterial BP, CVP, central line, Swan-Ganz cath, etc

152

Triple Lumen Catheter

Central Venous Catheter

Administers fluids, meds (non-compatible ok), parenteral nutrition, and used for hemodynamic monitoring (ex. CVP)

CVC=central venous cath
-inserted by HCP in 'central' vein
(subclavian, internal jugular, femoral)

Priority: check placement with chest x-ray!
Make sure tip is in lower-third of superior vena cava


Blue: IV fluids/CVP
White: TPN
Red: Blood (do not flush with saline if hemolytic rxn)

153

decompensated heart failure with frothy pink sputum

Administer diuretic (ex. furosemide) STAT.
-pulmonary edema needs to be resolved

154

Allen Test

Done before arterial cath placed.

-Have pt make fist
-Occlude radial and ulnar arteries using firm pressure
-Instruct pt to open fist
(palm will show pallor)
-Release pressure on ulnar artery
-Palm pink in 15 sec = patent ulnar artery

155

Check arterial cath

color
capillary refil
sensation
temperature
movement

Compare 2 sides or from baseline assessments

156

Possible abdominal aortic aneurism (AAA) repair complications

Pulses can be absent 4-12 hrs post-op d/t vasospasm.
If PEDAL PULSES DECREASE from baseline with cool, or mottled extremity 2 days post op, potential ARTERIAL OR GRAFT OCCLUSION/LEAKAGE

Dangerous!!!

Graft leakage:
-ecchymosis of scrotum, penis, or perineum
-increased abdominal girth
-report of groin, pelvis, or back pain
-tachycardia
-weak/absent peripheral pulses
-decreasing hob
-decreased urinary output

157

Preterm birth risks

-Infection (periodontal disease, UTI)
-#1 risk factor: Hx of spontaneous preterm birth
-previous cervical sx (ex. cone biopsy- weakens cervical support)
-tobacco and/or illicit drug use
-age <17 and >35
-malnutrition
-non-hispanic black women

158

von Willebrand disease

-Genetic bleeding disorder
-decreased vWF, needed for coagulation

Pt Teaching:
-med bracelet!
-Avoid NSAIDS
-Avoid high-risk activities (contact sports)
-keep nasal mucosa moist
-maintain gum integrity (soft bristled toothbrush)
-notify HCP s/s bleeding (severe joint pain/swelling, headache after injury, blood in urine/stool, uncontrollable nosebleed)

159

Opiod intoxicatoin

Decreased respiratory rate (<12/min)

Decreased mental status

Constricted (miotic) pupils (may not be in every pt)

Decreased/absent bowel sounds

***Naloxone (Narcan) reverses CNS and respiratory depression

Pruritus and nausea common/expected
Admin histamine blockers if needed

160

Newborn Safety

-Rear-facing carseat in back seat
-rolled blankets or car seat inserts may be used to support trunk if small baby
-supine position while sleeping
-sleep in crib in clothing, such as a sleep sack (baby warm without head covered)
-remove loose bedding and other objects from crib
-crib slats no more than 2.25 inches apart

161

Benzodiazepines

Anti-anxiety meds

alprazolam
lorazepan
clonazepan
diazepan

Take at bedtime

162

Catheter size based on fluid

BLOOD or Somewhat stable adult client needing a lot of fluid: 18-gauge

EMERGENCY: large bore, 14-gauge

General IV fluids and meds: 20-22

Children and Geriatrics w/ fragile veins: 24

163

Leukopenia
and
Neutropenia

Leukopenia: Reduced WBC count (normal 4,000-11,000)
***aka: agranulocytosis

Neutropenia: Reduced absolute neutrophil count (normal 2200-7700)

Neutropenic precautions:
-private room
-strict handwashing
-avoid exposure to sick ppl
-avoid all fresh fruits, veggies, flowers
-all equipment used disinfected

Neutropenia from cancer treatment puts pt at high risk for infection and sepsis (hypotension, elevated lactic acid)

164

Pinprick fail

peripheral neuropathy

165

Loss of hair on LE

poor perfusion

likely they also have poor wound healing

166

Rheumatic Fever

2-3 weeks after streptococcus pharyngitis

Major:
J<3NES
Joints, Heart, Nodules, Erythema, Sydenham chorea

Minor: Fever, arthralgias, increased sed rate/c-reactive protein, prolonged PR interval

2 major OR 1 major + 2 minor
(+ preceding strep)

167

Feeding Tube

-Crush, dissolve, and deliver each med separately
-Determine if med in liquid form
-Flush tube with sterile water before and after med admin

168

Chicken Pox

-Varicella
-Vesicular lesions
***Airborne spread secretions***
--put mask on child if in ER until placed in isolation negative airflow room
-Most contagious 1-2 days before the rash until shortly after onset (until crusted over)

*Herpes zoster (shingles) caused by same virus.
Airborne and contact precautions.

169

(-) vs (+) air pressure room

Positive:
pushes air out of room by increasing rate of flow. Used for immunosuppressed clients to prevent normal environment from entering.

Negative:
ventilation system that removes more exhaust air form the room that air allowed into the room. Prevents infection from spreading out into the environment. Used for airborne spread of disease.

170

Infective endocarditis

Vegetation over valves. Can break off and embolize. Life threatening!

-prophylactic antibiotics before for high-risk procedures (ex. dental work)

-Call HCP or 911 if any sign of embolization:
*slurred speech
*ONE-SIDED weakness/paralysis/pain
*painful/cold extremity

- IV antibiotics for several (4-6) weeks post discharge

-Report persistent fever

S/S may include:
Myalgia (muscle pain), chills, fever, joint pain, anorexia, petechiae, osler node (fingers), splinter hemorrhage (nail bed)

171

Post op:
radical prostatectomy

Avoid any rectal interventions such as straining, suppositories or enemas! Prevent stress on suture lines/surgical areas.

Encourage fluid intake, ambulation (DVT), cleaning indwelling cath w/ warm water and soap.

172

Erb's Point (cardiology)

3rd intercostal space
Left sternal border

Best place to hear S2

173

Bruit

Bell of stethoscope
Swish/buzzing sounds: turbulent blood flow in a narrowed blood vessel or aneurism

174

TPN discharge plan

-change tubing q24h
-immediately report red or drainage at insertion site
-monitor temp
-capillary glucose tests

175

RACE

RESCUE anyone in immediate danger
ALARM- activate a pull station alarm box
CONFINE fire by closing doors, windows, and shutting off main O2 supply
EXTINGUISH or EVACUATE

176

line infiltration

I.V. fluid or meds leak into surrounding tissues

lumen dislodged or displaced from lumen of the vein

Usually a place of flexion or person with brittle veins

177

Injury patterns of non-accidental traumas
(Pediatrics)

- Coup-contrecoup (shaking baby, head flopping)
- Subdural and epidural hematomas
-retinal hemorrhage
-frenulum tears and gingival lesions
-linear-type immersion burns
-long bone fractures (humerus, femur)

-burns the shape of household items
-repeated injuries at different stages of healing
-lapsed time between injury and care sought
-inconsistency b/w injury and caregiver explanation
-shaken baby syndrome

178

Shaken baby syndrome

Irritability or lethargy
Poor feeding
Emesis (vomit)
Seizures

179

Advanced directives

clients choices for medical care at the end of life, including resus status

AD>family wishes

180

Second degree Type 2 Heart block

Not every P wave has QRS complex (can be ratio)
Check PR interval

Need transcutaneous pacemaker
-stop potential cardiac arrest

181

Adenosine

SVT
creates transient heartblock

182

Warts and HPV Teaching

-warts can be treated but can return
-High risk HPV strains (16/18) increase risk of cervical, oral, and genital cancers
-Vaccine <26 years of age, more effective before sexually active
-PAPs start at 21 years old EVEN IF sexually active
-barrier methods reduce risk, but don't prevent transmission

183

TB Test

Mantoux test
PPD (purified protein derivative)
Airborne

bleb 48-72 hours
>5mm induration Considered POSITIVE if:
-HIV, organ transplant, recent contact with person with TB, immunosuppressed

>10mm induration Considered POSITIVE if:
-recent arrival (<5 yrs) from high prevalent country, healthcare employees, mild immunosuppression, kids <4 yrs, comorbidities (basically unhealthy)

>15mm induration Considered POSITIVE if:
person is healthy

Redness without induration (raised hard area) is NEGATIVE.

Bacillus Calmette-Guerin vaccine increase TB resistance in increased risk pts.
Can produce false positive.

184

After positive TB test

Further test: chest x-ray if not symptomatic
Active TB: isolation and airborne N95 mask

If pt transferred, they just need to wear surgical mask

185

Dabigatran (Pradaxa)

thrombin inhibitor
anticoagulant

Uses: atrial fibrillation, pulmonary embolus, DVT
Increased risk for: bleeding and hemorrhage

186

Phenytoin (Dilantin)

Anti-seizure medication

Therapeutic range:
10-20mcg/mL

Stop enteral feedings (1-2 hr), antacids, and calcium before taking.

*Early Toxicity: horizontal nystagmus
Gait unsteadiness
*Later: slurred speech, lethargy, confusion, coma

Gingival hyperplasia (puffy gums)- expected side effect
-Need good oral hygiene

Developing rash??? CALL DOC!
Could be start of Steven-Johnson Syndrome

Other risks:
-increased body hair
-folic acid depletion
-osteoporosis

187

Invalid Consent

If client still has questions indicating incomplete undersatnding

188

Restraints

Hourly neurovascular checks
Release for skin check and ROM q2h
Offer fluid, toilet, nutrition q2h

189

Prioritize Nurse Dx

Maslow's Hierarchy of Needs

190

Parent refuse meds or treatment

Open ended question
Assess parent knowledge first
--condition
--necessity of treatment

191

Respiratory syncytial virus (RSV)

-affects ciliated cells of respiratory tract
-excess mucus
-rhinorrhea (runny nose)
-fever, cough, lethargy, irritability, decreased feeding

Severe: tachypnea, dyspnea, poor oxygen exchange

Treatment: supplemental oxygen, suction, increase HOB, antipyretics, IV fluids, Palivizumab injection

Contact isolation, droplet within 3 ft of pt.
Transmission: DIRECT CONTACT WITH RESPIRATORY SECRETIONS.

192

Increased ICP Treatment

HOB >30 degrees
Head and body midline (promote venous return)
Stool softeners (prevent straining)
Calm environment (quiet)
Suction only when needed (no more than 10 sec)
Treat fever aggressively to decrease metabolic demands

193

Best CPR outcomes

defib early increases outcomes!
Chest clean and dry
Remove any medication patches before applying AED pads

194

Early Decelerations in Contraction Stress Test

Baby and Mom have symmetrical reactions
Onset, peak, and finish the same.

Cause: compression of head during contraction, results in vagal stimulation resulting in slowing fetal HR.
No intervention necessary

195

Late Decelerations in Contraction Stress Test

Baby onset at peak of Mom contraction.
Baby delayed compared to contraction.

Cause: Uteroplacental insufficiency, fetus has decreased oxygen reserves, maternal supine hypotension, placenta previa, abruptio placentae

Treatment: reposition mom, IV bolus, stop pitocin, give oxygen

***Needs further testing

196

Variable Decelerations in Contraction Stress Test

Random decrease (>15bpm for >15 sec) in fetal HR not associated with contraction.
R/T umbilical cord compression.

Change maternal position, check for prolapse, decrease or turn off pitocin, admin O2, prepare amnioinfusion

***Needs further testing

197

oligohydromnios
What is it?
Complications?

deficiency in amniotic fluid

Complications:
-pulmonary hypoplasia, might need resuscitation after birth

-umbilical cord compression, continuous fetal monitoring for variable decelerations

198

Prenatal Fetal Abnormalities
*Infections*

TORCH
Toxoplasmosis
Other (parvo/varicella-zoster)
Rubella
Cytomegalovirus
Herpes

199

Chest Pain
Treatment if MI

CP=potential MI...
MI sx: CP, diaphoresis, dyspnea, anxiety

Treatment:
ABC's
12 lead, cardiac markers, electrolytes
Apply O2
Insert 2 large-bore IV's and administer medications (nitro, morphine, etc)

200

IV Potassium

Heart monitor
Monitor IV frequently (K=tissue necrosis)
Max inf rate - 10 mEq/hr (PIV)
Max concentration 40 mEq/L
Assess renal function beforehand (potential K toxicity)

201

Petichiae

-reddish/purple pin points on skin
-r/t bleeding of capillaries from blood vessel injury or bleeding disorders

Dark skin patients: conjunctivae of eyes or buccal mucosae

202

Jaundice

Increased bilirubin
Dark skinned pts- check sclera, palms, and soles

203

Administer intermittent enteral feeding

-HOB 30-45 degrees before and 30-60 min after
-Assess tube placement
-Assess bowel function (sounds and residual volume...return residual to stomach)
-Flush tube 30mL
-Administer feeding

Abd cramps? too fast or too cold

204

Abruptio Placentae

bleeding, abdominal pain, uterine tenderness, increased uterine resting tone

205

Cushing Triad

Cause: INCREASED ICP

-Irregular respirations (Cheyne-Stokes)
-Bradycardia.
-Systolic hypertension with widening pulse pressure
(difference b/w systolic and diastolic)

206

High Potassium Foods

Rainbow colors!
Red- strawberry, tomato (NO APPLE)
Oranges- oranges, cantaloupe, carrots, apricot
Yellow- banana, potato
Green- avocado, kiwi
Blue from blue sea-fish
Violet-raisins

207

Low Potassium Foods

Asparagus, green beans, apples, apple sauce, green peppers, peas, grapes, grapefruit, peaches, pears, pineapple, cottage cheese, chicken, turkey, shrimp, tuna, eggs, bread, pasta, white flour, rice

208

Pre-eclampsia

New onset hypertension AND proteinuria or end-organ dysfunction AFTER 20 WEEKS GESTATION

S&S: headache, visual changes, edema (normal for all pregos)

HTN: >140/>90 on 2 occassions or 4 hrs apart
OR >160/>110 confirmed on repeat

Proteinuria: >300mg (0.3g) protein in 24-hr urine collection
OR protein to creatine ration 0.3
OR urine dipstick +1

End Organ Dysfunction:
Thrombocytopenia (<100,000)
Renal insufficiency (Creatinine >1.1)
Impaired liver function (2x normal AST and ALT)
***Normal AST 10-40/L ALT 7-56/L)
Pulmonary Edema
Cerebral or Visual Sx

209

Ostomy Care

-Change appliance 5-10 days
-Drink plenty of fluids
-Appliance needs to fit well (if loose, digestive enzymes on skin and will be irritated)
-Empty when 1/3 full
-Decrease intake of gas forming foods (onions, beans, broccoli, cauliflower)

210

Urosepsis

Bloodstream infection originating from urinary tract

Treatment:
-Fluid
-IV broad spectrum antibiotics (valsartan)
-Blood/urine culture (ideally before antibiotics)
-Heart monitor (potential hyperkalemia and sepsis)

211

Hyperkalemia
Avoid which meds?

Ace inhibitors (-pril) and ARBS (-sartan).
Used for htn secondary to renal disease.
Can worsen hyperkalemia
Don't consume salt substitutes- high in K

212

Risperidone

Use: Schizophrenia, bipolar, other mental disorders
Other atypical antipsychotics: quetiapine, olanzapine

Common S&S:
-Extrapyramidal Sx: akathesia (restlessness, fidget), parkinsonism (tremors, shuffling) *may be mistaken for agitation so watch closely
-Anticholinergic effects (dry mouth, constipation)
-Sedating Effects
-Change position frequently to prevent ortho hypotension
-weight gain

Serious S&S:
-Fever and Muscle rigidity: Neuroplastic malignant syndrome (potentially fatal)

213

Tardive Dyskinesia

repetitive, involuntary movements, such as grimacing and eye blinking

Cause: long-term use of neuroleptic drugs, which are used to treat psychiatric conditions.

214

3 P's of Diabetes

Polydipsia (thirsty)
Polyuria (>200mL/hr-increase in dilute urine)
Polyphagia (increased appetite)

215

Hyperglycemia

Polydipsia (thirsty)
Polyuria (excess dilute urine)
Polyphasia (hungry)
Headaches
Blurred Vision

TPN increases glucose, hyperglycemia = risk

216

Seizure activity RN interventions

Assist to safe position, protect head, clear area
Loosen tight clothing
Administer O2 if cyanotic
Document time and duration of sz

217

Bruising behind ear

AKA: Battle Sign
Follows head trauma
=basilar skull fracture
***Most common cause of traumatic death in kids

Other S/S: Blood behind tympanic membrane, periorbital hematomas (raccoon eyes), CSF leak from nose and ears

218

Aldosterone

adrenal glands
mineralcorticoid
RETAINS SODIUM AND WATER

Too much? fluid overload
Cushings
Hyperaldosteronism (Conns)

Not enough? Lose Na and H2O
Fluid volume deficit
Addison's Disease (ADD Steroids)

Decreased Na/H20--increase K
Increased Na/H2O--decreased K

219

ADH

Anti-Diuretic Hormone
Pituitary
RETAIN WATER WATER WATER!!!

Too much? Retain H2O in vascular space
Fluid volume excess
SAIDH- decrease urine output because ADH too high
*dilute blood concentrated urine
Decreased specific gravity and Na

*D*iabetes Insipidus- not enough ADH
D=Diuresis!!! still putting out dilute urine
NEEDS EXOGENOUS ADH
*urine diluteblood concentrated

Head trauma? Watch urine output. Potential ADH issue

220

Thyrioid Hormones

T3 - needs dietary iodine
T4 - needs dietary iodine
Calcitonin

221

Calcitonin

Decreases serum Calcium by driving it INTO THE BONES

222

Hyperthyroid

GRAVES DISEASE
nervous, sweaty, hot, wt loss, decreased attention span, increased appetite, fast GI, increased BP, increased size in thyroid (GOITER)
*exophthalmos=bulging eyes from fluid buildup behind eye. irreversible

Meds: antithyroid
propylthioracil/PTU, tapozole
Goal? EUTHYROID
Must TAPER and D/C meds!

223

Lugol's Iodine

Pre-op
Decreases vascularity to decrease bleeding
Use straw!!!

Why do we use straws? STAINS TEETH

224

Beta-blockers

Treatment for heart failure and hypertension
-olol
Decrease HR and BP (get apical pulse before admin! <50, contact HCP)
Also decreases ANXIETY
Good for Graves


MASKS HYPOGLYCEMIA- don't give to diabetics or pts with asthma

225

Radioactive Iodine

Decreases thyroid
Becomes Hypothyroid

For 24 hrs: don't go near babies or kiss anyone

226

Thyroidectomy

Teach how to support neck
interlace fingers behind neck to support
All personal items very close
No tension on sutures
Report any complaint of pressure near neck

Raise HOB to decrease edema around neck
Check for bleeding and pooling behind neck

HOARSENESS = Laryngeal nerve damage
could lead to vocal cord paralysis=trach
Keep trach set at bedside (hypocalcemia and swelling/vocal cord paralysis)

227

Parathyroid Removal?

There are 4 on Thyroid. Very possible to remove them during thyroidectomy
Parathyroid makes PTH--
PTH: increases serum Calcium by taking calcium from bones and bringing it to the blood.

CALCIUM ACTS AS SEDATIVE
No calcium? rigid, tightness, spasms

228

Hypothyroidism

No Energy/Myxedema

Babies with hypo: Sleepy, "well-behaved", barely cries, gaining weight
Adult: fatigue, slow GI, increase weight, constantly cold, slow/slurred speech, no expression.
Don't use heating pad! They might not be able to feel it.

Often confused with depression.

Treatment? Synthroid FOREVER.
Increased Energy, HR, BP.
Tent to have CAD- don't konw why
Watch for CP and rhythm changes

229

Parathyroid

CALCIUM CONTROL
***Calcium = sedative
Secretes PTH- pull calcium from bone to blood

Increased PTH- Increased serum calcium- decreased serum phosphate

Decreased PTH- Decreased serum calcium- Increased serum phosphate

Hyperparathyroidism=hypercalcemia=hypophosphatemia

230

IV Calcium

Pt needs to be on heart monitor
Decreases rate
Widens QRS- any widening STOP IV INFUSION

231

Hyperphosphatemia treatement

Amphojel
Binds phosphorus- makes phosphorus "invisible" and decreases the serum value
Leads to increase calcium

232

Adrenal Gland Components

Medulla: Epi and Norepi

Cortex: Steroids (glucocorticoids, mineralocorticoids, sex hormones)

233

Pheocromocytoma

Benign tumors releasing norepi and epi in boluses (not same amount continuously)

Increases HR and BP
VMA test (Vanillylmandelic Acid Test)
24-hr urine (discard first void, collect rest for 24 hr)
Stay calm throughout the day... no exercise, stress, etc. May alter results

Surgery to remove tumors

234

Steroids

From Adrenal Cortex
Glucocorticoids, mineralocorticoids, sex hormones

235

Glucocorticoids

protein catabolism Exogenous=decreased muscle
gluconeogenesis- inhibits insulin (CORTISOL!)
immunosuppression- decreases inflammation, slows healing
Maintains cardiac response to chatecholamines

236

Addison's Disease

Adrenal Cortex INSUFFICIENTY
ADD-ison's Disease= ADD STEROIDS
Decreased aldosterone (decrease in Na/H2O, increased K)
fluid volume loss- muscle weakness, decreased bowel sounds, nausea, GI upset, anorexia, hypotension, POTENTIAL SHOCK

*Hyperpigmentation (bronze skin)
*Hypoglycemia
***Steroids increase blood sugar
***No steroids- decreased blood sugar

Measure I and O, BP, wt -- fluid loss and med adjustment
RN Dx: fluid volume deficit

Treatment: mineralcorticoid= FLORINEF (aldosterone)

Addison's Crisis? extreme fluid loss, potential shock and vascular collapse

237

Cushing Syndrome

Disease: developed endogenously- body making too many steroids
Syndrome: exogenous administration of steroids

TOO MANY STEROIDS!!!
Exogenous glucocorticoids, minerocorticoids, sex hormones

S/S:
-hyperglycemia
-hypertension
-weight gain (truncal, buffalo hump, moon face)
-pink/purple stretch marks on abd, arms
-thinning skin, bruise easily
-muscle atrophy/weakness
-slow healing of cuts
-acne

MEN: decreased libido, ED, decreased fertility

WOMEN:
hirsutism (thicker facial and body hair)
irregular/absent menstrual period

Test: 24-hr urine

238

Prednisone

Glucocorticoid replacement

Decreases serum Calcium by making you excrete it through GI tract, pulls calcium from bones
*Calcium will look normal, but it's due to it being taken from bones
***Brittle bones!!! long term use

increase K, decrease Na, increase protein, increase calcium

239

Insulin Function

moves sugar and potassium out of vascular space into cells.
Without insulin- CELLS STARVING
Body will breakdown fat and form ketones
--ketones:acids, leads to metabolic acidosis

Insulin needs increase when pt with diabetes is sick!
illness + DM = DKA

240

Hyperglycemic Hyperosmolar Nonketotic Coma

HHNK
***TYPE 2 DIABETES

NON-KETOTIC (no ketones b/c pancreas still makes tiny bit of insulin that gets some sugar into cells)
Often confused with DKA
IS NOT ACIDOTIC!!!!
--Make enough insulin to not breakdown bodyfat (make ketones), but still extremely hyperglycemic

241

Diabetic Ketoacidosis

DKA
***TYPE 1 DIABETES!
Usually first sign someone has type 1 diabetes

-Not enough (or zero) insulin, increased blood sugar, 3 P's, fat breakdown leads to ACIDOSIS, leads to KUSSMAUL'S respirations (blow off excess CO2), decreased LOC from messed up pH.

S/S:
polyuria
abdominal pain
nausea/vomit

Treatment:
-IV insulin (d/c when glucose <200, then D5W)
-fluid resuscitation
-hourly BG monitoring
-Hypokalemia results as resolution, so admin K even when normokalemic (3.5-5)

***leads to metabolic acidosis. Can LEAD TO DEATH.

242

Pregnancy Trimester Lengths

Trimester 1: 1-13 weeks
Trimester 2: 14-27 weeks
Trimester 3: 28-40 weeks

243

3 Types of Pregnancy Signs

PRESUMPTIVE: amenorrhea (progesterone increase, not hcg), nausea, vomit, frequency (urinary), breast tenderness

PROBABLE: positive pregnancy test, hegars sign (soft uterus), goodells sign (soft vag cervix), braxton hix, pigment changes (dark line down abd), facial melasma, stretch marks

POSITIVE: fetal heart beat at 10-12 weeks
fetalscope at 17-20 weeks
fetal movement *felt by examiner*
*ultrasound*

244

Gravidity

# of times pregnant

Duration means nothing here
gravida 5 with no kids is possible!

245

Parity

# that reach viability
viability= 20 week minimum!!!

246

TPAL

Term (>=37 weeks)
Pre-mature (20-36 weeks)
Abortions (<20 weeks)
Living

If G in front=Gravidity
If M at end= Multiple

247

Naegele's Rule

Calculate Due Date

1st day LMP + 7 Days - 3 Months + 1 year

Only accurate +/- 1-2 weeks

248

Pregnancy Caloric Needs and Weight Gain

400 mcg/day FOLIC ACID prior to pregnancy (neural tube defects such as spinabifida)

1st trimester: 300kcal
protein increase to 60g/day
Normal for pt to gain ~4 lbs

2nd trimester: 1 lb weight gain per week

3rd trimester: 1 lb weight gain per week

249

Normal 1st Trimester S/S

nausea
vomiting
frequency (a lot of urination)
breast tenderness (all parts of pregnancy)

Drink water before topical ultrasound to push uterus to abd surface. Not necessary for transvaginal ultrasound.

VOID if an ultrasound is for a procedure

250

Normal 2nd Trimester S/S

NO nausea/vomit
NO frequency
breast tenderness
quickening (fetal movement around 16-20 wks)
FHR should be 120-160

251

Normal 3rd Trimester S/S

-frequency back again!
-nasal stuffiness
-fullness in ears
-edema
-Leukorrhea (whitish, mucoid vaginal discharge) increases throughout pregnancy

FHR 130-160

NOT NORMAL:
-copious thin/water leaking (might be amniotic fluid)
-dysuria
-cloudy urine
-flank pain

252

Common Pregnancy Discomforts

fatigue
hemorrhoids
varicose veins
heartburn
indigestion
swelling
nausea
ankle edema (elevate)
constipated (fiber, fluids, walk)
nasal congestion (saline nasal spray)

253

Prego blood pressure rule

+30/+15 of baseline!

254

Danger Signs in Pregnancy

Usually 3rd trimester:
-sudden gush of fluid
-Bleeding
-Persistent Vomit
-Severe Headache
-Abd Pain
-Increased Temp
-Edema
-No fetal movement

255

Leopold's Maneuver

Palpate abdomen to feel for head, back, and buttox.

WHY? Fetal back is where you listen to FHR.

VOID FIRST! Uterus should be midline

Do Leopold's Maneuver between contractions. Won't feel baby during contractions, just tightened muscles

256

Labor S/S

-Lightening (fetal head dropping into pelvis) 2 weeks before.
-Mom will feel less congested
-Increased urinary frequency
-Engagement- largest presenting part of fetus (head) at pelvic inlet at zero station.
-Sudden burst of energy (nesting)
-Stronger braxton hicks contractions
-Rupture of membranes
-Soft cervix
-some women get diarrhea

257

Contractions that indicate it's time for the hospital!

5 minutes apart
OR
when membranes rupture
**potential prolapsed cord, which is life-threatening

258

Non-Stress Test

>=2 increases of 15 bpm with fetal movement
Each increase should last 15 seconds
20 minute test

Healthy baby result: REACTIVE! accelerations are present

If HR does not increase, baby won't be able to handle labor and delivery

Get ready for NST:
-monitor
-whenever mom feels baby move, mom punches button

259

Contraction Stress Test

"Oxytocin Challenge Test"
*Only for high risk pregnancies! (pre-eclampsia, maternal diabetes, etc.)
Usually after 28 weeks because contractions being induced.
Results only good for 1 week.

Determines if baby can handle UTERINE CONTRACTIONS.
Contractions decrease blood floor to baby=potential hypoxia

Ideal Result: NEGATIVE!!! no late decels!!!

Bad Result: Late decelerations. Deliver that baby!

260

True Labor

Regular contractions
Increase in frequency/duration with contractions
***Discomfort in BACK, radiates to abdomen
***INCREASED pain WITH ACTIVITY

-bloody show does not indicate true labor. Occurs a few days before onset.

261

False Labor

Irregular contractions
***Lower Abdominal and Groin pain
***DECREASED pain WITH ACTIVITY (Braxton Hicks)

262

Epidural Anesthesia

Position: left side, legs flexed, not a ton of back arch
-Usually no headache b/c not in spinal fluid
*Most common complication: HYPOTENSION
--IV fluids (NS or LR), change position, lie on side to decrease vena cava compression, change sides every hour

263

Pitocin

Oxytocin
1-to-1 care (for NCLEX)
Never lay prego SUPINE!

Complications:
*Fetal brady- turn on left side
*Hypertonic labor- contractions that won't stop can kill baby (no oxygen getting to baby during contractions)
*Uterine Rupture: VBAC at high risk!!! C-section scar may rupture.

Complete UR: through uterine wall into peritoneal cavity. Sudden sharp/shooting pain, Absent fetal heart tones
Incomplete UR: through uterine wall, not peritoneal cavity, internal bleeding, possible late decels, hypotonic with contractions

Late Decels with Pitocin? TURN OFF!!!
Left side, oxygen 8-10 non-rebreather, bolus LR, call HCP

264

Postpartum Hemorrhage Causes and S/S

Causes: uterine atony (no tone), bleeding, lacerations, retained fragments, forceps delivery

Early: >500cc in 1st 24 hrs
Late: 24hrs-6wks

High HR (should be 50-70 for 6-10 days post)
Excessive Vaginal Bleeding (>1 pad/hr)
Decreasing blood pressure (should be stable post)


*Retained placenta or any products may lead to hemorrhage
*Check firmness of fundus. If not going back to normal (involution) worry about hemorrhage!
Should be near umbilicus

265

Lochia and Clots

Postpartum

Rubra (dark red) 3-4 days
Serossa (pinkish brown) 4-10 days
Alba (whitish yellow) 10-28 days/up to 6 wks
Pt teaching: report any foul smelling lochia! endometritis

Clots: no larger than nickel
Diurese for 1st 24 hours post partum
Inspect legs for DVTs

266

Postpartum Perineal Care

If episiotomy, tearing, or surgery:

-intermittent ice packs 6-12 hrs to decrease edema
-warm water rinses
-sits baths 2x/day

267

Breastfeeding

Initiate ASAP after birth (bonding and uterine contractions)
Breast pump if mom can't be near baby in 1st hr
Increase kcal by 500
8-10 glasses fluid/day (need more fluid/milk)
--if not, potential plugged duct and leads to mastitis
Do not clean breasts with soap, only warm water. Soap=drying
Breast pads needed. Wet breasts decrease skin integrity

268

Post-partum infection

Within 10 days of birth
-E.coli
-betahemolytic strep
Will need cultures and antibiotics.
If taking antibiotics while breastfeeding, take immediately after feeding baby

Teach proper hygiene: front to back and hand washing

269

Mastitis

Bacteria: Staphylococcus
Usually 2-4 weeks
Cause: not breastfeeding properly!
Need to EMPTY breast with each feeding.
Stagnant milk=inflammation

Treatment:
Still want to BF? Empty affected breast as often as possible (BF and/or pump), hot shower to help breasts leak, always offer affected breast 1st, penicillin (take immediately after feeding).
Analgesics (ibuprofen)

Don't want to continue BF: cooling breasts! Cooling breasts helps decrease milk supply and constrict vessels

270

Newborn Care

Suction
Clamp/Cut Cord
Maintain Temp
APGAR (minutes 1 and 5)
***At least 8-10
**Most babies 9 because of purple hands/feet (acrocyanosis)

AquaMEPHYTON- Vit K shot in vastus lateralus
*needs clotting factors! Will make own after eating for a week
Erythromycin- eye ointment

271

Baby Umbilical Cord Care

dries and falls off 10-14 days
Starts to dry in about 24 hrs
Turns black 2-3 days
Fold diaper below cord
NO IMMERSION until it falls off
report any s/s infection
wet=moist=bacteria=infection

272

Baby Hypoglycemia

Not getting enough glucose from mom
High Risk: LGA, SGA, Preterm, mom was diabetic

Sugar bottle!

273

Jaundice

Pathologic Jaundice: 1st 24 hrs--ABO or Rh incompatible

Physiologic Jaundice: after 24 hrs
hemolysis of excess RBC's releasing bilirubin
immature liver

274

Rh Sensitization

People either have or don't have Rh factor in blood.

Rh Negative- if body exposed, will make antibodies (Rh sensitization).
Ex. Mom (-) and Baby (+), mom treats (+) like foreign body to her (-) blood.
Blood may come in contact when placenta separates at birth, during miscarriage, amniocentesis, trauma to abd.

Treatment: RH IMMUNOGLOBULIN (stops body from making antibodies). Given at 28 weeks.
*RhoGAM given after birth (within 72 hrs)
Destroys fetal cells in moms blood.

If not treated, first baby unaffected but next pregnancy could lead to complications. Mom's blood will destroy baby blood (erythroblastosis). Baby won't have blood (anemic, hypoxic), won't grow.

Baby: direct test in cord
Mom: indirect test

275

Decerebrate Posture

"Extensors predominate"
***Indicates severe head/brain injury***
-arms and legs straight out
-toes pointed down
-head/neck arched back

Arms opposite of decorticate posture (flexed)

276

Hypothermia

weak and thready pulse because of cold
should be normalized when warm
CLIENT NOT DEAD UNTIL WARM AND DEAD
may need prolonged resus

277

Near-Drowning

-hypothermia common (warm IV fluids, blankets, air)
-weak thready pulses common (may need prolonged resus)
-wheezing on auscultation STILL BREATHING!
---bronchospasm
crackles=aspirated fluid- could lead to resp distress syndrome

ED management:
-advanced airway (intube and/or mech vent)
-aggressive O2
-establish IV access and IV fluids (warm if hypo)
-cardiac monitor for arrhythmias and fluid imbalances

*do not turn frequently- cause Vfib

278

Renal Calculi Plan of Care

analgesia for pain
increase fluid intake
assist with ambulation (promotes clearance)
strain urine for stones (for analysis)

279

Uterine Contractions
1st stage labor

45-80 seconds (NOT more than 90 seconds)
2-5 every 10 min, no more than every 2 min
Strength: measure at peak, 25-50mmHg
--NOT more than 80 mmHg
Resting Tone: measure b/w contractions
avg 10mmHg (NOT more than 20mmHg)

***Increase in values indicate uteroplacental insufficiency

280

Phalen's Maneuver

back of hands together and elbows flexed

Testing for carpel tunnel syndrome

281

Heel-to-Shin test

Assess cerebellar function

282

Romber test

eyes closed, feet together

Testing vestibular function (perception of head in space)
proprioception (perception of body in space)
vision

283

IV Oxytocin Complications and RN action

increased contractions, increased resting tone, increased FHR with decreased variability

Stop infusion
Reposition client to side-lying
Admin oxygen by facemask
Notify HCP
Record/Document findings

284

Teletherapy

(external beam of radiation)
-Proetect skin from infection (no rubbing, itching, scrubbing, wear loose clothing)
-Cleans with lukewarm water and mild soap
-Only cream/lotion HCP approved
-Avoid extremes in temp (head pads, ice packs)

285

Concussion

Minor TBI
-brief disruption in LOC
-amnesia regarding event (retrograde amnesia)
-headache

286

TBI

*not concussion! More serious*
-worsening headache, vomiting, sleepiness, confusion (all indicate increased ICP)
-Visual changes
-Weakness or numbness

287

SIADH

Syndrome of Inappropriate ADH
Increased ADH secretion

increased serum osmolarity, decreased serum Na
decreased urine output
increased urine specific gravity (concentrated)

OPPOSITE: Diabetes insipidus

Treatment:
fluid restriction (<1000)
oral salt tabs
hypertonic saline (at first)
vasopressin receptor antagonists
Strict I/O
Neuro checks

288

Severe Preeclampsia

IV Mg prescribed (depresses CNS)

Plan of Care:
Check Deep tendon reflexes
Calcium gluconate as reversal agent
Seizure precautions!---
-Decrease environmental stimuli
-Dim lighting
-Pillow to protect head
-Side-lying position
-O2 and Suction available
-Bed in low position
-Loosened clothing

289

SIRS

Systemic inflammatory response syndrome
d/t trauma, ischemia, infection (i.e. sepsis) or other distributive shock process causing system infectoin

2 of the following:

Temp >100.4 or <96.8

HR >90

Resp >28 OR pCO2 <32mmHg

WBC >12,000 OR <4000 OR >10% band

290

Peritonitis
-causes
-RN action

common and serious complication of peritoneal dialysis

-Also potentially occurs with diverticulitis-
*pain in other quadrants of abdomen, rigidity, guarding, rebound tenderness*

1st: cloudy peritoneal effluent
Later: low grade fever, chills, rebound tenderness, abdominal pain

RN: collect peritoneal effluent from drainage bag for culture and sensitivity. May need antibiotics.
Do not place in high-fowlers... will increase abd pain

291

Ischemic Stroke

Most common presentation: sudden onset of numbness/weakness of arm and/or leg

Kids with sickle cell at high risk (relative to other peds)

292

Intussusception

One portion of intestine prolapses and telescopes into another portion

-"currant jelly" stools due to blood/mucus
-sausage-shakped mass in RUQ
-screaming
-knees drawn up to chest

293

Hemophilia

Primarily males
Lack of clotting factors
Desmopressin (DDAVP) stimulates release of clot factor VIII

*Pts with hemophilia A need factor VIII administered after potential bleeding injury before any other treatment.

Long term complication: JOINT DESTRUCTION

Teach injury prevention
Avoid contact sports
Avoid aspirin and ibuprofen (platelet inhibition)
Avoid IM inj, SQ preferred
Dental hygiene to prevent gum bleeding, soft toothbrush
-MedicAlert bracelet

294

Hepatic Encephalopathy

Too much ammonia! Liver not functioning to remove toxins from blood.
-Axterixis (flapping of hands)
-Fetor Hepaticus (musty, sweet breath)
-Increased ammonia levels
-Sleep disturbances/irritability
-AMS/lethargy
-slurred speech

295

Theophylline

Bronchodilator
Low therapeutic index
Avoid caffeine
Monitor drug levels o avoid toxicity:
--anorexia, nausea, vomit, restlessness, insomnia
Dose based on PEAK drug levels
--measured 30 min post-dose

296

Gluconeogenesis

Stress induced hyperglycemia
>140
Glucose target to void hypoglycemia is 140-180
Occurs in ICU pts when they are unable to fight off infection.
NOT always diabetic!!! 80% ICU pts with hyperglycemia not diabetic, but under physical stress

297

Gingko Biloba

Taken to relieve symptoms of intermittent claudation
(cramping in leg from exercise r/t obstructed arteries)

298

Cold Injury Action from Home

Rewarm in warm water (104 degrees) to promote blood flow and oxygenation
See HCP

do NOT rewarm and refreeze=death (think of chicken)
do not massage affected area!

299

S3 sound

Normal in young adults and athletes
Indicates congestive heart failure in older adults

The third heart sound is caused by a sudden deceleration of blood flow into the left ventricle from the left atrium.

Heart with bell of stethoscope at apex

300

Breast self exam

Not sub for routine exams!

Regular periods: 5-7 days after menstruation
Post-menopause OR irregular menses: choose same day monthly
Oral Contraceptives- when new pack started

301

Post-op Prostatectomy
Concerning S/S

Contact HCP for the following:
bleeding, passage of clots, decreased urinary stream, urinary retention, S/S UTI

302

NSAIDS

ibuprofen
aspirin
celecoxib
naproxen
ketorolac
indomethacin

---used for analgesic, anti-inflammatory, antipyretic
Toxicity: Nephrotoxic and ototoxic
TINNITUS

OD? tachy, hypotension (secondary to blood loss/dehydration from nausea and vomiting)

INCREASE risk of thrombotic events in clients with CAD

303

Acetaminophen

Tylenol
Fever reducer
Pain relief

304

Nitrate Medication Function

prevents angina
Vasodilate peripheral vessels and decrease cardiac workload and coronary artery workload

305

Hepatitis C

Virus
Pts usually have chronic infection
Expected finding: ALT and AST (liver enzymes) >2-3x normal!

306

Ventilator Associated Pneumonia

Second most common Healthcare Acquired Illness

purulent sputum, (+) sputum culture
leukocytes 12,000
fever (>100.4)
new onset or progressive pulmonary infiltrates on chest x-ray suggesting pneumonia

307

Continuous Subcutaneous Insulin Infusion

-Fewer swings in blood glucose levels and hypoglycemic events
-still admin bolus before carbs
-check blood sugar at least 4x/day (4-8 common)
---Fasting, pre-meal, 2 hrs post meal, bedtime, 3am
-Open-loop cannot respond to change in glucose levels

Some closed loop with continuous BG monitoring!
Still need daily calibration

308

Breast cancer
Breast lumps

Mobile lumps usually ok!

Inflammatory breast cancer: red, warm, and has orange peel (peau d'orange) pitting appearance.
Breast mass may or may not be present.
Cancer in lymph glands in affected side armpit

309

Calcium needs for 1-3 year olds

500 mg/day
leafy dark greens
calcium fortified juice and cereal

Vitamin D increases Ca absorption
-direct sunlight
-fish oil, egg yolk, Vit D cereal

310

Airborne Infections

Most contagious! Priority for isolation questions.
-Measles (Rubeola)
-TB
-Varicella
-Severe acute respiratory syndrome

***N95 Respirators!!!
+gowns and gloves
***Negataive airflow room

311

Droplet Infections

2nd most contagious
-Viral Influenza (flu) -*and contact*
-Meningitis (Neisseria meningitidis)
-Pertussis (whooping cough)
-Rubella
-Strep group A

-Surgical mask for routine care
-Private room
-As needed: gloves, gown, goggles/face shield (wound care, suctioning)

312

Contact Infections

MRSA (bathe with moistened cloths with chlorhexadine)
Scabies

313

Annual Flu Vaccine

Recommended for EVERYONE >6 months whose not allergic to ingredients

314

Prevent VAP

minimize mechanical irritation and bacterial access to the lungs
-sealed endotrach tube cuff >20cm H20 (15mmHg)
-routine oral hygiene with chlorhexidine
-elevate HOB
-avoid gastric over distension
-minimize sedation, extubate ASAP
-only suction when clinically indicated! not on schedule

315

Alcohol Intoxication Intervention

IV thiamin (Vit B1) followed by IV glucose
-prevents Wernicke encephalopathy

316

Alcohol Abuse Recovery

Should:
-show accountability
-understand/express
consequences
-use insight to face reality
-use coping skills and non-chemical alternatives.
-Encouraged to set goals for personal growth.
-Abstain from any/all alcohol consumption

317

Fetal Ultrasound Timeline

7 wks- fetal heart tones
8wks- major organ systems in place/function in simple ways
12 wks- sex can be determined by genitalia if in good position

16-20 wks fetal movements felt

318

Ophthalic Ointment Admin

1) Hand hygiene
2) Tilt head back, pull down lower lid, and look up
3) Squeeze thin strip onto lower lid from inner to outer edge
4) Close eyes gently for 2-3 min after application

319

Suspected Meningococcal Meningitis Nursing Care

Safety:
Droplet precautions and NPO status (for somnolence)
Comfort:
minimize stimuli, raise HOB slightly, remove pillows

Droplet precautions continue 24 hrs after initiation of antibiotic therapy

320

Loop diuretics

-Furosemide (IV may cause ototoxicity, 4mg/min only)
-Torsemide
-Bumetanide
*used for CHF or renal insufficiency
"everything wasting"
-INCLUDING K!!!

321

Angiotensin II Receptor Blockers
ARBS

-sartan
Losartan, valsargan, candesartan
ANTI-HYPERTENSIVE

Uses:
clients who cannot take ACE inhibitors (-pril).
***No dry cough!!!
Heart failure, MI, DM neuropathy, stroke prevention

Block angiotensin 2 action.

***Angioedema can be severe and affect breathing!

*WILL NOT affect fluid status of client with acute HR.

322

Beta Blockers

-lols
Metoprolol, bisoprolol, carvedilol
ANTI-HYPERTENSIVE

Decreases HR (control of tachyrhythmias), less force, therefore decreases BP

**MASKS HYPOGLYCEMIA= NO diabetics
***CONSTRICTS SOME SMOOTH MUSCLE=NO Asthmatics


Potential withdrawal

323

Ace Inhibitors

-pril
lisinopril, captopril, enalapril
ANTI-HYPERTENSIVE

First line for hypertension, especially in diabetics.
***Protective in kidneys
*-Decreases peripheral vascular resistance WITHOUT increasing HR, CO, or contractility.

-DRY COUGH
-ANGIOEDEMA
-Temporary increase in creatinine
-HYPERKALEMIA (decrease aldosterone secretion=loss of H2O and Na)
*Measure K before administration
--avoid K sparing diuretics (spirinolactone, amiloride, triamterene)
NO PREGO'S!!!

Check BP prior to admin.
Commonly given to pts post-MI to prevent vent. remodeling (hypertrophy)

Asians (specifically Chinese) high risk for COUGH.
Black people- high risk for cough and angioedema

324

Migrane

unilateral pulsating headache
sensitivity to light

325

Hypertensive encephalopathy

Medical Emergency
-caused by sudden elevation in BP (hypertensive crisis)
-leads to cerebral edema/increased ICP

-look for hx of htn, vision issues, epistaxis

S/S: severe headache, VISUAL IMPAIRMENT, anxiety, confusion, EPISTAXIS, sz, coma

326

Trismus

inability to open mouth due to a tonic contraction of muscles used for chewing

-may indicate peritonsillar or retropharyngeal abscess
-maintaining adequate airway essential

327

C. Difficile Medication

Metronidazole (Flagyl)
anti-infective drug
COMMON FOR VAG INFECTIONS
Metallic taste/dry mouth
(ok for pregos, dark urine expected)

if severe: oral vanco
IV vanco ineffective

Antibiotics reduce normal bacteria in body, alows other bacteria (like C.Diff) to take over. Grows in intestinal tract. Causes diarrhea.

328

Proton Pump Inhibitors

-zole
omeprazole, pantoprazole

Reduce stomach acid production
Take before meals

Assoc w/ development of C.diff

329

Asthmaticus

Acute exacerbation of asthma that remains unresponsive to initial treatment of bronchodilators

330

Parkland Formula

Equation needed for IV resus after burns

(4mL * wt in kg * percentage of body burned) = 24 hr requirement.
1/2 given first 8 hrs!

Convert to L if needed

331

Dilutional Hyponatrma

Na <135
Caused by excess total body water in clients with heart failure

Diuretics and fluid/salt restriction

332

Kawasaki Disease

aka: mucocutaneous lymph node syndrome

*systemic vasculitis*
Crucial when at home:
-Monitor for fever every 6 hrs for first 48 hrs post last fever

>5 days fever, bilateral non-exudative, conjunctivitis, mucositis, cervical lymphadenopathy, rash, extreme swelling, GALLOP heart rhythm, decreased UO

IV Immunoglobulin used to prevent HEART DISEASE.
Aspirin also used.
Primary goal: CORONARY DISEASE PREVENTION

333

Tricyclic antidepressants

amitriptyline, nortriptyline, desiprmine, imipramine

Common for neuropathic pain

Side effects: orthostatic hypotension, dizzy, constipation, urinary retention, confusion, photosensitivity

Pt Teaching: change positions slowly

334

Urinary Cath Care to Prevent UTIs

-routine hand hygiene
-Clean perineal area with soap and water routinely
-Keep bag below bladder and off ground
-keep cath and tubing free of kinds
-use sterile technique when collecting specimens
-encourage fluid intake if not contraindicated

Do NOT routinely irrigate
Rt use of antiseptic cleansers NOT shown to prevent infection

335

Heparin and platelets

Normally: heparin prevents clotting and does not affect the platelets (components of the blood that help form blood clots)

Immune system response sometimes causes HEPARIN INDUCED THROMBOCYTOPENIA (decreased platelets)

When pt on heparin look for and report on:
-decrease of >=50% from baseline
OR
-below 150,000

336

Advanced Directives

-Copies in med record, with pt, and healthcare proxies
-Two witnesses required, should not be healthcare proxies listed on doc
-Does not need to be notarized
-Clients wishes, not a medical order
--not a DNR form!

337

Preconception Care

-400 mcg Folic Acid
-avoid alcohol, smoking, tobacco
-dental appt in case of periodontal disease (assoc with adverse pregnancy outcomes)
-rubella vaccine 4 wks prior to pregnancy
-normal BMI (18.5-24.9)

338

Osteomalacia

REVERSIBLE bone disorder
-caused by vitamin D deficiency
-weak, soft, and painful bones

-fall precautions
-encourage light to moderate activity
-increase calcium, phosphorus, vitamin D
-Take OTC Vit D

339

Enoxaparin

low-molecular-weight heparin

Right or left side of the abdomen
At least 2 INCHES FROM THE UMBILICUS

340

Acute Pancreatitis

-life threatening
-abd pain radiating to back
-rise in pancreatic enzymes (amylase, lipase)

-Can be caused by endoscopic retrograde cholangiopancreatography (ERCP)

341

Aortic Disection

Intimal layer tears, blood between inner (intima) and middle (media) layers.

Ascending: Chest pain radiating to back
Descending: Back pain, abdominal pain

-Frequently abrupt onset
-"worst ever" "tearing" "ripping" pain
-hypertension contributing factor

Treatment:
LOWER BP!
SURGERY

342

Septic Shock

Infectious agent from localized infection source (UTI, wound) enters bloodstream.

-Fever OR hypotherma (>100.4 <96.8)

-Hypotension (systolic <90 or MAP <65)

-Prolonged Cap Refill

-Tachycardia

-WBC >12,000 or immature neutrophils (bands) >10%

-Decreased mental status

-Decreased CVP (below 2)

343

Systemic inflammatory response syndrome
and
Sepsis

SIRS:
-inflammatory response
--fever, tachycardia, tachypnea

Sepsis:
SIRS + infectious source identified (pneumonia, UTI, etc)

Septic Shock:
Sepsis + HYPOTENSION DESPITE ADEQUATE IV FLUIDS

MODS:
Septic Shock + Multiple organ system damage (acute resp distress syndrome, AKI, low platelets)

344

Transurethral resection of prostate

TURP
continuous bladder irrigation for 24-36 hrs to flush small clots and prevent obstruction
-reddish-pink drainage expected

345

Obstructive sleep apnea

Apnea (>10 sec)
Diminished airflow (hypopnea)

Findings in Pt:
Night- repeated periods of apnea, loud snoring, interrupted sleep
Day- morning headaches, irritability, excessive sleepiness

346

Botulism

-muscle paralysis
-found in soil and contaminates food
-improperly canned or stored food!
-kids under 1 yr get it from honey

Manifestations:
-descending flaccid paralysis (start from face)
-dysphagia
-constipation (smooth muscle paralysis)

347

Sprained ankle treatment

"RICE"

Rest 24-48 hrs

Ice 10-15 min every hr for 24-48 hrs

Compress

Elevate 24-48 hrs

Analgesia (NSAID) every 6 hrs prn

Exercise rehab program when pain subsides

348

Peritoneal dialysys

-Cath in peritoneal cavity, dialysate (dialysis fluid) infused, tubing clamped for 20-30 min (dwell phase), unclamped to allow dialysate to drain via gravity

Insufficient flow usually from constipation blocking catheter holes!
-admin stool softeners as prescribed
-maintain bag below abdomen
-check tubing for kinks
-reposition pt (side-lying)
-assist with ambulation

349

Peak flow meter

Measures peak expiratory flow rate
-for moderate to severe asthma

Exhale as quickly and forcibly as possible through mouthpiece of device to obtain reading

-move indicator to 0 before using
-use after short-acting bronchodilator rescue MDI to check response

350

Tetracycline

tetracycline, dosycycline, minocycline

-Take on empty stomach
-Avoid antacids or dairy products (2 hrs after antacid)
-Take with full glass of water
-Photosensitivity
-Reduces effectiveness of oral contraceptives (like rifampin)

Do not take at bedtime- assoc with esophageal irritation

351

RN action for
Abdominal wound evisceration

-Remain calm and stay with pt
-Have someone notify HCP immediately and get sterile supplies
-Low-Fowlers position (<20 degrees) and knees slightly flexed
-Assess vital signs for shock (repeat every 15 min)
-Cover with sterile dressings saturated in NS
-Document
-Immediately NPO in case of surgery

352

Quadriplegia

aka: tetraplegia
Lower limbs completely paralyzed
Upper limbs completely or partially paralyzed

C-spine injury

Airway and oxygenation priority

353

Therapeutic vs. Non-therapeutic Communication

Therapeutic: reflecting, open-ended questions, suggesting strategies or resources

Non-Therapeutic: minimization, automatic responses, and leaving clients who have strong emotions

354

TPN

-Make sure CVC is in place with chest x-ray!!!
-Filters used to remove precipitate and microorganisms
-Hypertonic solution (>10% glucose) used, increases risk for infection
-0.22 micron filter used for non-lipid TPN
-1.2 micron filter used with lipids
-Baseline blood glucose and finger-sticks every 6 hrs
--- Desired 140-180 for hospitalized adult clients
-Hyperglycemia is risk, also in enteral feedings

355

Torsades de Pointes

Caused by widened QT from
Hypomagnesemia

First line treatment: IV MAGNESIUM
Defib may be necessary

Meds that can cause TdP:
heloperidol (Haldol), methadone, ziprasidone, erythromycin

356

TB intradermal injection

-Use a 27-gauge 1/4 inch needle with a 1 mL tuberculin syringe
-Administer injection on inner forearm at a 10-degree angle with bevel up
-Make a wheal (bleb)
-Avoid rubbing site after injection

357

Newborn of diabetic mother

Risk for hypoglycemia and hypocalcemia.
Hypo in newborn <40

Symptoms: JITTERINESS, IRRITABILITY, hypotonia, apnea, lethargy, tamp instability

Transitional time (first 6 hrs post birth) increased risk for hypoglycemia as fetus produces insulin in response to mom's glucose.

358

Penicillin Allergy
also avoid...

Cephalexin
any cephalosporin

Start with cef- or ceph-

359

H1 receptor antagonists

Fexofenadine
Cetrizine
Levocetrizine
Loratadine

Decrease inflammatory response by blocking histamine receptors.
-Given during type I hypersensitivity rxn (allergic rhinitis, conjunctivitis, hives)

360

Asthma and nasal polyps

sensitivity to NSAIDs

361

Sumatriptan

Selective serotonin agonist
-Treat migraine headaches
-Triptan drugs constrict cranial blood vessels to help migraine

Contraindicated in CAD and uncontrolled hypertension b/c of vasoconstriction and increased angina risk

362

Plagiocephaly

flat head syndrome in infants

-alternate head positions
-minimize time against firm surface (eg. carseat)
-tummy time for 30-60 min/day
-placing toys on opposite of favored/affected side to encourage head turning

363

Ampule medication withdrawl

-Blunt filter needle to prevent aspiration of glass
-Filter needle can be discarded and an injection needle can be attache (IM: 20-gauge, 1 in needle)

364

Expected finding in atrial septal defect

Murmur (systolic) with a fixed split second heart sound

365

Cardiac Tamponade

LETHAL!
Fluid in pericardial space
-Decreases cardiac output
*Increases CVP b/c of external pressure
*Decreases BP b/c of hemorrhage

MUFFLED/DISTANT HEART TONES
-narrowed pulse pressure
-distended neck veins
-paradoxical pulse (pulsus paradoxus): when BP >10mmHg on expiration than on inspiration
-reduced LV cavity space
-dyspnea/tachypnea
-tachycardia

TREATMENT:
Pericardiocentesis: needle to draw out blood

366

Coarctation of the Aorta

-Narrow aorta
Difference between upper and lower extremities:
UPPER- increased BP, strong brachial/radial pulses, well-developed
LOWER: decreased BP, weak/absent femoral pulses, underdeveloped, claudation (ischemic pain)

367

Anaphylactic Shock Management

Call for help!
1. Ensure patent airway, admin O2
2. Remove insect stinger
3. IM epi. Repeat dose every 5-15 min
4. Elevate legs
5. IV fluids
6. Bronchodilator (albuterol)
7. Antihistamine (diphenydramine for pruritius)
8. Corticosteroids (methylprednisolone for swelling)
9. Cricothyrotomy (tracheostomy with severe laryngeal edema)

368

Skeletal Traction tasks for UAP

-Assist with active and passive ROM
-Notify RN of sensation changes
-Remind pt to use incentive spirometer
-maintain proper use of pneumatic compression devices
-remind client to move frequently using overhead trapeze

369

Toxic epidermal necrolysis

-acute skin disorder, most commonly associated with a medication reaction, that results in widespread erythema, blistering, epidermal shedding, keratoconjunctivitis, and skin erosion
-severe form of Stevens-Johnson syndrome.
-MAJOR CAUSE OF DEATH: sepsis!! Infection=critical.

-sterile wound care
-reverse isolation and strict sterile techniques
-monitor for infection
-vital signs and output monitored for hypovolemia
-hypothermia prevention (85 degree room temp)
-pain management
-eye care

370

PTSD

-Increased anxiety
-reliving event
-feeling detached from others

3 categories of Sx:
1. Reexperiencing the event
2. Avoiding reminders of the trauma
3. Increased anxiety and emotional arousal

NO auditory hallucinations, changing emotions, delusions, or lethargy

371

Pica

compulsive craving for non-food substances

Often r/t iron deficiency anemia

CHECK hgb and Hcg levels for anemia

372

Thoracentesis

-Treat pleural effusion
-Needle between ribs into pleural space to drain fluid
-complications: pneumothorax (needle into lungs and deflates), bleeding (less common)

In case of pneumothorax watch:
level of alertness, resp rate, resp effort, O2 sat, and lung sounds.
Chest X-ray before and after

Tension pneumo= trach deviation and cardiac compromise

373

Tachysystole

>=5 contractions in 10 minutes

Do not increase uterotonic drugs (oxygocin)! Might compromise fetal oxygen.
Decrease or d/c oxytocin

374

Reye Syndrome

Encephalopathy/cerebral edema
Acute fatty liver failure

Kids cannot have:
Salicylate!!!
-Bismuth subsalicylate (pepto Bismol)
-Aspirin

...especially during a viral infection (influenza, varicella)
OR
pt with Kawasaki disease

increased serum ammonia
fever
lethargy
acute encephalopathy
altered hepatic function

375

Meds kids can have

-Acetaminophen every 4 hrs for fever

-Ibuprofen every 6 hrs for body aches

376

Delirium

"Acute cognitive dysfunction"
Manifestations in a critically ill pt who was previously A and O:
-Acute onset
-Impaired consciousness
-Fluctuates
-Reversible
-global impairment (place and time)
-short-term memory loss
-increased lethargy

Predisposing factors in hospitalized its:
-advanced age
-neuro issue (stroke, dementia)
-polypharmacy
-infection/comorbidities
-acid-base imbalance
-impaired mobility
-surgery (post-op)
-untreated pain

377

Dementia

Gradual (months to years), consciousness intact, progressively worse, irreversible, remote memory spared

378

Depression

Gradual (months), consciousness intact, EPISODIC, reversible, moderately impared focus/concentration

379

Psychosis

No acute onset.
Usually oriented but have auditory (not visual) hallucinations
-Symptoms, not disorder (ex. schizophrenia symptom)

380

Fifth disease

PARVOVIRUS B-18
"slapped face"
erythema infectiosum

One of TORCH infections.
Can cause spontaneous abortion/ fetal abnormalities

Viral illness
human parvo!
School-aged kids (people pups)
-communicable only prior to symptom onset
--cover mouth and nose when coughing/sneezing

Rash on cheeks
Joint pain (ibuprofen ok!)
Recover within 7-10 days
Isolation not usually required

381

Acute blood loss

Medical emergency!
-Supine position (lower HOB) to maintain perfusion to the brain and other vital organs
-Follow this with interventions (IV access/fluids, vitals, hgb/hct)

382

Laparoscopic cholecystecomy
Post-op Nursing

-Surgical removal of gallbladder

-focuses on prevention of respiratory complications.
-Place in the SIMS POSITION to facilitate movement of carbon dioxide (CO2) utilized during surgery to fill the abdominal cavity.

383

Flumazenil

Antidose for a benzo OD

Benzo endings:
-azepam
-azolam

384

Nitroprusside

NITRO=VASODILATION

Potent vasodilator used in hypertensive urgencies

RN action: Check BP

385

Raynaud's phenomenon

Usually triggered by cold exposure
-digital arteries constrict and blood flow impaired
-red, numb, tingling, throbbing, and cold
-episodes 15-20 in

386

Physical Restraints

Limb (ankle, writs)
Belt

-involuntary
-not temporary for medical procedure (ex. elbow restraint <30 min for blood draw on toddler)

387

Post op bleeding

-Serosanguineous (pink) drainage expected
-Saturated dressing with sanguineous (bright red) indicates excessive blood loss
--posible hemorrhage
--report immediately to HCP

388

Digoxin

Lanoxin
Cardiac glycoside for heart failure and a-fib
-positive inotropic effects (increases cardiac output)
-negative chronotropic effects (decreases heart rate)
-Range 0.5-2.0

*Prior to admin check pulse (<60) hold med

Report:
Cardiac Sx
Visual changes (scotomas, blindness, color vision)
GI changes (nausea, vomit)
neuro manifestations (lethargy, fatigue, weakness, confusion)

389

Chest Tube sections

Left to Right:

A: Suction Regulation
SUCTION CONTROL CHAMBERr: amount of suction applied
Continuous, gentle bubbling

Water Seal Chamber (middle)
BUBBLING IS BAD HERE!
C (low part): Air leak gauge. Bubbling indicates air leak.
B (tall 2 balls): Should see inspiration and expiration *tidaling*

D: Collection Chamber
Collect drainage from client (serosanguinous). Not bright red1

390

Strong Antibiotics and Risks

Vancomycin
Gentamicin (aminoglycosides)

Nephrotoxic
Ototoxic

Constantly check kidney and hearing function

Vanco: red man syndrome- upper body flushing
Trough level: 10-20 mg/L

391

Statin and Fibrate Complications

Statin: atorvastatin, rosuvastatin
Fibrates: gemifibrozil, fenofibrate

Muscle aching and cramping.

Statins: take at night or before bed
-most cholesterol synthesized during fasting state, so statins needed in system at that time
-Contraindicated for severe liver or muscle injury

392

Methotrexate

-Treats cancer, RA, psoriasis (malignancies)

-Immunosuppressant
---increased risk for infection
-Decreases RBC
---bone marrow suppression
-teratogenic NO PREGOS!
-Hepatotoxic, avoid alcohol!

393

CVP

-Central venous pressure
-Right Ventricular Preload (volume in V at end of diastole)

Normal: 2-8 mmHg

Increased indicates fluid volume overload:
-periph edema
-increased dilute urine output
-acute rapid wt gain
-JVD
-S3 heart sound in adults
-tachypnea, dyspnea, crackles in lungs
-bounding periph pulses

Low CVP:
deficient fluid volume:
dry mucous membranes, hypotension

394

Nicardipine

Cardene
Potent Calcium Channel Blocking Vasodilator

Priority RN intervention is to monitor hypotensive effects of drug

395

Acute stroke presentation

requires "permissive hypertension" during the first 24-48 hours to allow for adequate perfusion through the damaged cerebral tissues.

396

Guillain-Barre Syndrome

Rare disorder
Immune system attacks nerves
Ascending paralysis
-weakness
-ataxia
-bilateral paresthesis progressing to paralysis

Progresses rapidly or over 2-3 wks

397

Active labor

"transition:
8-10 cm
Bloody show
Urge to push (Ferguson reflex)
Coach through breathing techniques and AVOID PUSHING until fully dilated to prevent cervical tauma

398

ACE inhibitors and ARBs

-prils
-sartans

***May potentiate hyperkalemia***

ACE- decrease aldosterone (promotes Na retention and K excretion)

399

Lactulose

Cirrhosis and hepatic encephalopathy

-Promotes excretion of ammonia via fecal elimination (2-3 soft stools/day)

-decreases intestinal absorption of ammonia

-given with juice, milk, or water
OR
rectally via enema
-can be given on empty stomach for more rapid effect

400

Orthostatic BP Procedure

1. Have the client lie down for at least 5 minutes
2. Measure BP and HR
3. Have the client stand
4. Repeat BP and HR measurements after standing at 1- and 3-minute intervals

401

Greasy, foamy, foul-smelling, fatty stool

chronic pancreatitis

402

Light gray "clay-colored" stool

Bilary obstruction

403

Small, dry, rocky hard masses for stool

constipation

404

Black tarry stool

"coffee ground stool"
aka: MELENA
Upper GI bleeding
NSAID overuse

405

Bright red bloody stool

Lower GI bleeding

406

Blood present on surface of stool

hemorrhoids

407

Diabetic foot care

Keep clean, dry, and free from irritation

1. wash feet daily warm water mild soap
2. inspect for abrasions, cuts, sores
3. to prevent injury, use cotton or lambs wool to separate overlapping toes, but nails straight across and file along cures of toes, do not go barefoot, mild food powder for moisture, absorbent socks with aligned seams
4. avoid OTC products on abrasions
5. do not sit with legs crossed, exercise daily
6. report any issues/infections immediately

408

Cast Care

Nothing placed down cast! No lotion. No powder.
Use cool hairdryer to help itching.

S/S of infection (sores, purulent drainage, foul odors) and persistent itching report to HCP.

Frequent neurovascular checks if pt has vascular impairment (changes in extremity color, temp, pulse) or periph neuro impair (loss of sensory or motor function)

409

Alcohol Withdrawl

-always screen for heavy use of alcohol or benzodiazepines as withdrawal is potentially life-threatening and avoidable.

Mild 6-12 hrs: anxiety, insomnia, tremors, diaphoresis, palpitations, GI upset, intact orientation

Seizures 12-48 hrs: single or generalized tonic-clonic
Hallucinations 12-48 hrs: visual, auditory, or tactile, intact orientation, stable VSs

Delirium tremens 48-96 hrs: confusion, agitation, fever, tachycardia, hypertension, and diaphoresis, hallucinations
DT's can be prevented with benzo administration

Benzo's used to help with withdrawl. -epam

410

Features Assoc with Hip Fracture

Ecchymosis/tenderness
Groin and hip pain with weight bearing
**Muscle spasm*** for protection and stabilization
Shortening
Abduction or adduction of the affected
External rotation

411

PTSD

Re-experiencing the traumatic event:
Examples include intrusive memories, flashbacks, recurring nightmares, and feelings of intense distress/loss of control or strong physical reactions to event reminders (eg, rapid, pounding heart; gastrointestinal distress; diaphoresis)

Avoiding reminders of the trauma:
Examples include avoidance of activities, places, thoughts, or other triggers that could serve as reminders; feeling detached and emotionally numb; loss of interest in life; inability to set goals; and amnesia about important details of the event

Increased anxiety and emotional arousal
Examples include insomnia, irritability, outbursts of rage, persistent anger and/or fear, difficulty concentrating, hypervigilance, and exaggerated startle response

Persons with PTSD are typically restless and hypervigilant and have trouble falling or staying asleep.

412

Breastfeeding

on demand, whenever infant displays hunger (crying rooting reflex)
8-12x/day

15-20 min/breast for newborns

"tummy to tummy" at nipple level

Common positions are clutch hold, cradle, cross cradle, and side-lying

nipple and part of areola

Incorrect latch: insert a finger to break the suction prior to moving infant

413

pudendal nerve block

Used when too late for epidural!
Late Second Stage of Labor

-infiltrates local anesthesia (ie, lidocaine) into the areas surrounding the pudendal nerves that innervate the lower vagina, perineum, and vulva.
- least maternal/newborn side effects
-It does not relieve contraction pain but does relieve perineal pressure when administered in the late second stage of labor

414

Otitis Media
vs
Otitis Externa

Otitis Media:
-usually kids <2 after resp infection
-high fever, ear pain, irritability/restlessness, loss of appetite, and pulling on the affected ear
-bulging red tympanic membranes

Otitis Externa:
-swimmers ear
-infection of outer ear
-severe pain experienced with direct pressure on tragus (anterior flap Rose has pierced) and pinna (whole outer ear)
-normal tympanic membrane, infection in external ear canal,

415

Meniere disease

AKA: endolymphatic hydrops
***excess fluid in inner ear
-vertigo attacks (minimize with quiet, dark room and avoiding sudden head movements, turn off TV)
-tinnitus
-hearing loss
-aural fullness

416

ALT/AST test indications

LIVER INJURY!
-HEPATITIS/other hepatic disorders
-Viral hep
-excess alcohol intake
-OTC meds (acetaminiphen), -certain herbal and dietary supplements (green tea extract, kava, comfrey)
-IV illicit drug use (increases risk for hep B/C)

417

Target range for glucose control in pts receiving nutritional support

140-180
Hypoglycemia (serum glucose <70 mg/dL [3.9 mmol/L]) can be due to slowing the rate of the infusion.
Although it occurs less frequently in clients receiving total parenteral nutrition (TPN) than hyperglycemia (serum glucose >180 mg/dL [10.0 mmol/L]) does, hypoglycemia can lead to life-threatening complications
(eg, seizures, nervous system dysfunction).

418

Otalgia

Ear Pain

Normal after adenotonsillectomy due to irritation of the 9th cranial nerve (glossopharyngeal) in the throat.

419

Hypertensive Crisis

Elevation in blood pressure (BP) >180 mm Hg systolic and/or >120 mm Hg diastolic
***evidence of organ damage (eg, kidney damage, retinopathy).

RN: Prioritize Neurological Assessment b/c of stroke risk

Goal: slowly lower BP using IV antihypertensive medications (eg, vasodilators) to limit end-organ damage.

420

Clodine

Very potent antihypertensive
Abrupt D/C can result in serious rebound hypertensive crisis

Other common side effects:
3 D's
Dizziness
Drowsiness
Dry mouth

421

Isoniazid (INH)

-is a first-line latent tuberculosis (TB) drug


Adverse Side effects:
HEPATOTOXICITY (jaundice, anorexia)
PERIPH NEUROPATHY (interferes with Vit B6 aka pyridoxine)

Avoid alcohol
Avoid other hepatotoxic agents (acetaminophen)
Take pyridoxine (Vit b6)
Avoid aluminum-containing antacids (Maalox)
Report vision changes

Report S/S of severe adverse effects:
Hepatoxicity (jaundice, vomiting, dark urine, fatigue)
Peripheral neuropathy (numbness, tingling of extremities)

422

Dumping syndrome

-complication of the surgically reduced gastric capacity (ex. Billroth II, gastrojejunostomy).
-rapid emptying of hypertonic gastric contents into the duodenum and small intestine.
-abdominal pain, diarrhea, nausea, vomiting, dizziness, sweating, palpitations (tachy), hypotension.

Dietary changes to delay gastric emptying:
Small frequent meals
Foods high in protein and fat
Drink fluids between means
Avoid high carbs (dry foods with low carbs ok)
Diet high in fiber
East slowly
Avoid sitting up after a meal

423

Baby Ultrasound Timeline

7 wks- fetal heart tones
8 wks- major organ systems in place (function in simple ways)
12 wks- sex if in good position
16-20 - quickening (fetal movement)

424

Near Drowning ED

-advanced airway management (intub/MV as needed)
-agressive O2
-Establish IV access/IV fluids (warm if hypothermic)
-Monitor heart arrhythmia and fluid imbalances

Frequent turning-cause Vfib

425

Baseline glucose for hospitalized adult

140-180
>180 hyperglycemia
<70 hypoglycemia
<100 should be avoided

426

Torsades de Pointes

widened QT
HYPOMAGNESEMIA
Treat with IV Mg and maybe defib

427

Compartment Syndrome

post-op/post fracture reduction
Neurovascular checks performed 1st
*****If pain NOT RELIEVED by pain meds or is out of proportion to injury notify HCP*****
-Pain with passive motion

Early S/S: pain, numbness, unrelieved pain by meds, diminished/absent pulses, pallor, coolness, cyanosis

Put extremity LEVEL WITH HEART (not above)
Do NOT apply heat/ice

428

Sodium Polystyrene Sulfonate

Kayexalate
Retention enema
Given to pts with increased K levels
Resin in SPS replaces Na for K

429

Barium enema

Contains contrast for colon in fluoroscopic x-ray

Pre-procedure:
-Take cathartic (mg citrate, polyethylene glycol) to empty stool from colon
-Clear liquid diet day before (no red/purple liquids)
-No eating/drinking 8 hrs before procedure
-May have abdominal cramps during procedure

Post-procedure:
-White stools after procedure
-Take laxative
-Plenty of fluids and fiber

***Retention of barium can cause fecal impaction or bowel obstruction resulting in BOWEL PERFORATION AND PERITONITIS!
Constipation is a big deal.

430

Fleet enema

Hypertonic solution, pulls H2O from bowel, softens stool, then defecation

431

Neomycin enema

Medicated
Decreases bacteria before colon surgery

432

SLE

positive antinuclear antibody titer (>1:40)
elevated erythrocyte sed rate (normal <30 mm/hr)
Lupus nephritis (treat ASAP to preserve kidneys)
--increased serum creatinine >1.3 Increased BUN

Butterfly (malar) rash
Photosensitivity
Rash anywere exposed to sunlight
Weight loss
Fever/increased infection
Raynaud's phenomenon (cool/numb parts in certain situations. Think of holding snowball)

433

Polycythemia Vera

-Excess amt RBC, WBC, and platelets produced
-Bone marrow disorder
-Increased risk for clots b/c of increased volume, vascular stasis of blood

***Periodic phlebotomy to remove 300-500mL blood through venipuncture***

Pt should report swelling, redness, or tenderness in leg
Follow up immediately
Stroke also complication

434

Mitral Valve Regurgitation

LV pumps blood through aorta and some backflows into LA
-Decreased CO
-Dilation of LA
-Pulmonary edema
-Often asymptomatic
-Report any new sx of heart failure
***dyspnea, orthopnea, weight gain, cough, fatigue)
HEART FAILURE REQUIRES IMMEDIATE INTERVENTION

435

Heart Failure
Diastolic and Systolic

Diastolic: Heart can't fill (stiff thick chambers/impaired relaxation)
Systolic Heart can't pump (reduced Ejection Fraction)

436

Cervical Cancer Risks

HPV and anything that increases risk to get HPV

-sex before 18
-multiple partners
-immunosuppression
-oral contraceptives
-STDs
-Tobacco use

437

Kernig's Sign

(+)=MENINGEAL PAIN
pt supine
flex pts hip and knee
try extending leg at knee
(+)= back pain and resistance to straightening
Bilateral = even more (+)

438

Brudzinski's Sign

(+) MENINGEAL IRRITATION
pt supine
put hand behind pts head
lift head (flexing towards chest)
(+)= INVOLUNTARY FLEXION OF HIPS AND KNEES

439

Otalgia

Ear Pain

440

Hypertensive Crisis

>180 and/or >120mmHg + organ dysfunction

Goal: slowly lower BP using IV antihypertensives

441

Amlodipine

Calcium channel blocker
Used for HTN
Slows HR
Relieves CP

442

Hemianopsia

Only portion of visual field from each eye
R-sided CVA may have L-sided hemianopsia
Turn head to left to see more of visual field

443

Tiotropium

and Umeclidinium
Inhaled steroids
Powder via special inhaler
-long acting 23-hr anticholinergic med
Rinse mouth out afterwards

do NOT decrease inflammation, but RELAX airway by blocking parasympathetic bronchoconstriction

444

Ipratopium

Short acting anticholinergic used as a RESCUE for COPD/ASTHMA


do NOT decrease inflammation, but RELAX airway by blocking parasympathetic bronchoconstriction

445

Epiglottitis

aka: supraglottitis
Sudden-onset medical emergency due to Haemophilus influenza.

-Soar throat
-Fever w/ toxic appearance
+ 4 D's:
-dysphonia (muffled voice)
-DROOLING
-dysphagia (difficulty swallowing)
-distressed rest effort
-leaning forward

-RN action: tripod position
-will need intubation or surgical airway
PREVENTABLE!!!
Cause: Haemophilus influenza type B (HiB)
standard 2- and 4-month vaccine
Rarely seen in vaccinated kids

446

Ethambutol

TB drug
OCULAR TOXICITY (vision loss/double vision/blurred vision)

Loss of red-green discrimination
Monitor eyes regularly (baseline eye exam)

447

Sucralfate

Antacid
Take before meals to decrease irritation of ulcers

448

Coombs Test

Screens for Rh sensitization
Indirect Coombs Test: mom
Direct Coombs Test: baby

Rh (-) mom will get screened if any TRAUMA occurred that may cause bleeding.

Rh immune globulin (RhoGAM) given to ALL Rh (-) pregos at 28 weeks and within 72 hrs of birth as well as post maternal trauma
NOT EFFECTIVE once sensitization has ccured

449

Serum alpha-fetoprotein

Screen for neural tube defects

450

Rubella

German Measles
red rash
Droplet (sneeze, cough, mucus/saliva contact)
Mom to baby by pregnancy, labor, nursing

MMR VACCINE!!!
Measles, mumps, rubella

451

Meningitis

fever, severe headache, nausea/vomiting, nuchal rigidity, photophobia, AMS, increased ICP

-W/ sepsis or hypotension? FLUID!
-vasopressors (constrict blood vessels) epi, norepi
-Labs/cultures
-Empiric antibiotics (within 30 min admission)
-Head CT BEFORE LP (increased ICP or mass lesions lead to brain herniation)
-assist with LP

452

Cranial Nerves

On Old Olympus Towering Tops A Finn And German Viewed Some Hops

I-Olfactory-Smell
II-Optic-visual
III-Oculomotor- pupils constrict/extraoccular movement
IV-Trochlear- extraoccular/down and inward
V-Trigeminal-face sensation, biting, chewing
VI-Abducens- Extraoccular/ lateral movement
VII-Facial- Close eyes and smile
VIII-Acoustic- Hearing/Romberg
IX-Glassopharyngeal-Gag reflex
X-Vagus-"AH" uvular and palate movement
XI-Spinal Accessory -Turn head and shrug shoulders
XII-Hypoglossal-stick tongue out

453

Metabolic Syndrome

>= 3 health factors
Increase risk for Stroke, DM, and CVD

-Abdominal Obesity (>40M, >35W)
-Increased Triglycerides (>150) R Hypertriglyceredemia drug treatment
-Decreased HDL (<40M, <50W)
-HTN (>=130/85) OR hypertensive drug treatment
-Fasting blood glucose >=100 OR hyperglycemia treatment

454

Lumbar Puncture

Spinal Tap
Increase fluids
lie flat for 4 hrs (prone or supine)
Headache common
Continued leaking fluids- site not sealed! Blood patch needed

455

Ankylosing Spondylitis

Inflammation disease
Hunch/curved spine

-posture, daily stretching, swimming or racquet sports
-stop smoking/breathing exercises
-pain: moist heat and NSAIDS
-immunosuppressant and anti-inflammatory meds
-rest during flare ups
-sleep on back with FIRM mattress to decrease spinal flexion

456

Cleft Palate

Risks: aspiration, malnutrition
Inability to create suction

Feeding:
-upright
-bottle/nip away from CP
-special bottle (nip always filled) "cross-cute" and preemie nips (no sucking needed)
-burp often
-feed slowly 20-30 min
-feed 3-4 hrs

457

Beck Triad

Cardiac Tamponade

Hypotension
Muffled heart sounds
Distended neck veins

Pulsus Paradoxus: large decrease in stroke volume, SBP, and wave amplitude during inspiration
"Normal" SBP fall: 10 mmHg
Normally BP rises with inspiration and falls with expiration

458

Acid-fast Bacilli Smear and Culture

Confirms TB after positive TB test and Chest x-radiograph

Sterile sputum 3 consecutive mornings

459

Chronic Arterial Insufficiency

*Oxygenated Blood Not Getting To Tissue*

Pain: Intermittent claudation (progresses to rest pain)
Pulses: Decreased or maybe absent
Color: Pale when elevated, red with lowering of leg
Temp: Cool
Edema: Absent or mild
Skin Changes: thin, shiny, loss of hair over food/toes, nail thickening
Ulceration: If present will involve toes or areas of trauma on feet (painful)
Gangrene: May develop
Compression: Not used

460

Chronic Venous Insufficiency

*Blood Getting To Tissue, Can't Get Away!*
--Not oxygenation problem (don't choose give 2L NC)

Pain: None to aching pain depending on dependency of area
Pulses: Normal (may be difficult to palpate d/t edema)
Color: Normal (may see petechiae or brown pigmentation w/ chronic condition)
Temp: Normal
Edema: Present
Skin Changes: Brown pigmentation around ankles, possible thickening of skin, scarring may develop
Ulceration: If present will be on sides of ankles
Gangrene: Does not develop
Compression: Used (need fluid to get back!)

461

Cardiac Output

Amt of blood pumped by the heart per minute

HR x SV (bpm x amt per beat)

462

Preload

End Diastolic Volume
Stretches R or LV
CVP=measurement (2-8 normal)

463

Afterload

Pressure in aorta and peripheral arteries that LV has to pump against during systole
(systolic pressure)

464

Fibrinolytics

Dissolve clot blocking blood flow to heart
Decrease size of infarction

Streptokinase (a lot of peopel allergic)
Tenecteplase (1x psh)
Aletplase (stroke too!)
Reteplase

Heart: 6-8 hrs!!!

Complication? Bleeding

Contraindications:
Brain tumor (IC neoplasm), IC bleed, suspected aortic dissection, internal bleeding

Stroke: 3 hrs

465

5 P's

Neurovascular Check:
Pain
Pallor
*Pulselessness (mark before procedure)
Paresthesia (tingling, burning, etc.)
Paralysis

466

CHF

Coronary Heart Failure

Blood not moving forward (cardiomyopathy, valvular disease, endocarditis, acute MI, htn)

Left sided: THINK LUNGS!
pulm cong, dyspnea, S3 sound, restless, blood-tinged sputum, crackles, Displaced PMI, paroxysmal nocturnal dyspnea (sense of SOB that wakes up pt)

Right Sided: "Cor Pulmonate"
Think Venous system
enlarged organs, pitting edema, wt gain, distended neck veins (JVD), ascites

NO NSAIDS!
Cause sodium retention.

467

Diagnose CHF

Swan Ganz catheter
Central line cath
-measures pressures inside of the heart

Not pumping? increased heart pressure will show with increased Swan reading

Other Tests:
High BNP (peptide released when Vent stretched)
Chest X-ray- enlarged heart, pulm edema
Echo- EF, measures pressure

468

Systolic HF vs Diastolic HF

Systolic: Heart can't contract/eject
Diastolic: Ventricles can't relax and fill

469

Spironolactone

Aldactone
Diuretic
May be given to decrease aldosterone (salt and water) levels

When H2O and Na decrease, K increases!!!

K-SPARING!!!!!!!

470

Artery vs Vein
Elevate extremity?

Elevate Veins
Dangle Arteries

Artery issues/occlusions prevent blood from getting to tissue. Elevation makes that worse

Veins can't get fluid away from tissue, elevate to move fluid along

471

Buerger's Disease

Arterial Disease
Men
inflammation of veins and arteries (mainly arteries)
--Cuts off O2
Usually LE's (toes)

Cause? Heavy smoking, getting too cold, intense emotions

Treat: stop smoking, avoid cold, hydrate, wear shoes that fit well, maybe surgery, avoid trauma to feet

472

Raynaud's Disease

Arterial Disease
Female=Fingers!
Vasoconstriction of vessels.
Get's upset/cold/smokes and her fingers (both hands) turn white, then blue, then red
PAINFUL and can ulcertae

Avoid cause: ex. if hands hurt when reaching into the freezer, wear gloves

473

Echolalia

Repeating word or phrase over and over
"echo"
one of many schizo symptoms

474

Neologism

Make up new words with no real meaning
"neo-logic"
one of many schizo symptoms

RN: seek clarification!" "I don't understand"
Do not reinforce behavior

475

Korsakoff's Syndrome

Common in alcoholism
*Thiamin/Niacin (V Vits) deficiencies

Disoriented to time
Confabulate (make up something to fill in gaps)
--memory disturbance

476

Wernickes Syndrome

Common in alcoholism
Thiamin (Vit B1) deficiency

labile emotions
moody
tires easily
ok at first, ten soemthing sets them off

477

Antabuse

Deterrent to alcohol
--any type of alcohol will cause effect
--couph syrups, aftershave, colognes,e tc

478

Hemothorax

Blood in pleural cavity

NOT pneumothorax= air in pleural cavity

479

Crutches on Stairs

UP:
"Up with the Good"
Strong leg, weak leg, crutches

DOWN:
"Down with the Bad"
Crutch, bad, then good

480

Walking with Walker

Pick up, put in front, walk into walker

Sliding? Hazard if pt's walker has rubber stoppers. They need tennis balls to make sliding safer

481

D-Dimer

Blood test
Will increase with pulmonary embolism
*Indicates if clot located ANYWHERE in body, not just lungs

482

hemoptysis

coughing up blood

483

Fractures:
S/S
Complications

Continuos pain, unnatural movement, muscle spasms, possible deformity, crepitus (bones grating together), shortening of extremity (r/t muscle spasms), swelling, discoloration

Complications: Shock, Compartment Syndrome, Fat Embolus (usually long tone fx, pelvic fx, crushing injury)

484

Fat Embolus S/S

Depends on where emboli travels:
-petechia or rash over chest
-dyspnea
-confusion
-conjunctival hemorrhage
-"snow storm" chest x-ray (fat in lungs)

Usually long bone fracture
First 36 hrs post injury

485

Traction

-Pulling on part of body
-Decreases muscle spasms, reduces (realigns) bones, immobilizes
-Should be continuous *never relieve traction w/o order!*
-Weights hand freely
-Ropes move freely
-Knots should be secure

Skin Traction: tape material stuck to skin and weights pull against it. Skin not penetrated!
Bucks, Russell's

Skeletal Traction: applied direclty to bones w/ pins and/or wires. Used when PROLONGED traction needed
Steinman Pins (through the knee), Gardner-Wells Tons, Halo Vest

486

Skin Traction Types

BUCKS--mostly hip fx
-Weights hang off end of bed
-1 pulley and food being pulled horizontally towards end of bed
-Supine or semi-fowlers (20-30 degrees)

RUSSELL'S- moslty femoral fx
-3 pulleys
--1 above knee to pull leg upward while also being pulled by 2nd pulley towards end of bed

487

Post-Op Amputation

-Tourniquet at bedside in case of hemorrhage
Elevate on pillow first 24 hours
--after that, elevate food of bed! (don't want contractures)
-Want to prevent hip flextion!!!
BKA=2 possible contractures (hip/knee)
--put pt in PRONE POSITION to extend hip.knee
Phantom Pain- diversional activity and pain meds

Rehabilitation:
-Stump shaping for prosthesis-cone shape
-Massaging stump increases circulation and decreases tenderness
-"Toughen" Stump: press into soft pillow, then firm pillow, then the bed, then the chair

488

Hemodialysis

-Machine acts as glomerulus
-If pt allergic to HEPARIN, can't be hemodialyzed
---unless another solution with anti-clot property can be used (ex. sodium citrate.
-Pts with unstable cardiovascular system can't tolerate hemodialysis

-Done 3-4x/week
-Avoid K, high Na, and Phosphorus in diet
-Eat more protein
-Learn how much fuid allowed to drink

489

Glomerulonephritis

-Inflammatory rxn in GLOMERULES (kidney filter)
-Usually caused by STREP
-sore throat, malaise, headache, Proteinuria, increased BUN/Creatinine, facial edema, decreased UO, anemia

-Increase Carbs to increase energy! Dn't want protein to break down and make Urea that can't be excreeted

490

Nephrotic Syndrome

*Inflammatory response in glomerulus
ANY INFLAMMATION! (NSAIDS, heroin, Hodgkins, bacteria, viral, allergic rxn, DM, SLE)
*big holes=protein leaking into urine
*hypoalbunemic - can't hold onto fluid in vessels-THIRD SPACING!
*Full-body edema (ANASARCA)
*No fluid in vessels=kidney response to increase fluid-(renin-angiotensin system kicks in and produces aldosterone)
*retention of Na and H2O

Bed rest (to diurese)
Prednisone- decrease inflammation (now immunosuppressed)
***Increase protein! ONE KIDNEY DISEASE YOU CAN INCREASE PROTEIN

Lasix and Albumin infusion

491

Meds that could cause intra-renal damage

"MYCINS", loop diuretics
-use with caution in clients with renal damage

492

Peritoneal Dialysis

-Dialysate WARMED (vasodilation) and infused into peritoneal cavity by gravity through catheter
-2000-2500 mL stays in for ordered amt of time (dwell time)
-Bag lowered and fluid along with toxins drained

Effluent/drainage/fluid:Should be clear, straw-colored
Cloudy=infection!

-WHO? Pts who can't take hemodialysis like cardiovascular pts

-Fluid not coming out? Reposition or turn from side to side
-Diet: increased fiber and protein

2 Types of Peritoneal Dialysis
-Continuous Ambulatory Peritoneal Dialysis (4x/day, 7 days/week, need strong client with no disc disease, arthritis, or colosomy)
-Continuous Cycle Peritoneal Dialysis (night time only)

493

Continuous Renal Replacement Therapy

Usually ICU setting
-kidney filter utilized
-Hemodialysis more aggressive
--300mL of blood in hemo machine, only 80mL in CRRT machine
-Better for unstable pts whose CV status can't handle hemodialysis

494

Ultrafiltration

Only pulling off water for pts only retaining water
May be utilized with peritoneal dialysis or hemodialysis

495

Kidney Stones

Renal calculi, urolithiasis
Don't Kill You!
Pain
WBC's in urine
Hematuria (not inough to throw you in shock)
RN Action: Urine specimen ASAP and check for RBC's

Treatment:
-Ketolorac (Toradol), Hydromorphone (Dilaudid), Promrthazine (Phenegran), Ondansetron (Zofran)
-Increase fluids
-Strain urine

-EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY (ESWL)
Will CRUSH stone!

496

Cups of milk for 14 month old daily?

2-3 cups

497

School age child daily caloric intake?

1600 avg
based on weight

498

FLACC assessment

Pain assessment
2 months - 7 months

Face
Legs
Activity
Crying
Consollability
0=no pain
10=worst pain

499

Wong Baker Pain Rating Scale

Faces :)
>=3 Years

500

Numeric Scale for children of what age?

>=5 Years old

501

Pediatrics
Observable signs for respiratory dysfunction

Accessory muscle use
Flaring nostrils (nares)
Circumoral pallor
Sternal retractions
Pallor
Cap refill >3

502

Respiratory Syncytical Virus

RSV
-Acute viral infection affecting bronchioles
-Affects children 2 months-2 years
-Begins with simple URI and then progresses
-nasal discharge, nonproductive paroxysmal cough, tachypnea and flaring nares, wheezing

503

Asthma
S/S and Dx

Cough, SOB, audible wheezing, prolonged EXPIRATORY WHEEZING, restlessness, cyanosis, tripot posiiton

Identify triggers!!!

Infants: Reactive Airway Disease (RAD)

-Chronic cough, no infection
-Pulmonary Function Test
-Spironmetry function >5 years old
-Peak expiratory flow rate (PEFR) (age, race, height gender dependent)

504

Asthma Treatment

GENERAL:
-Chest physiotherapy (percussion, vibration, squeezing of chest and then breathing exercise- ex. blowing a pin wheel)
-allerg shots
-small frequent meals
-cold air, breath through nose
-encourage fluids to thin secretions (not cold- bronchospasm)

ACUTE:
-humidified O2
-epi Sq or Tebutaline Sq
-Rescue meds: IV corticosteroids, prednisone, Solu-medrol
**Beta 2 agonists: Albuterol, Metaproterenol, Terbutaline
--After neb treatment, kid will get worse before better. Airway opens and they will wheeze
**Bronchodilator: Salmetrol, aminophaline, theophylline

LONG TERM CONTROL (preventer meds)
-corticosteroids (inhaled by MDI or neb, po)
0MDI's
-Beta 2 agonist

***MDI at any age with correct spacer

505

Hirschprung's Disease

Piece of intestines=no nerves
No nerves = no peristalsis in that location

AKA: aganglionic MEGA COLON that results in mechanical obstruction along bowel.
-Sigmoid Colon
S/S- Constipation, abdominal distention, ribbon-like/foul smelling stools

Clinical Features:
-bilious vomiting
-abd distension
-failure to pass meconium
-failure of internal anal sphincter to relax
-difficulty feeding

Fatal complication:
ENTEROCOLITIS
-fever/lethargy
-explosive foul-smelling diarrhea
-rapidly worsening abdominal distention

506

Pyloric Stenosis

Obstruction of gastric outlet.

-Results in projectile vomiting d/t pressure, usually after feeding.
-Immediately hungry again.
-Olive shaped mass in epigastrium region (near umbilicus)
--Enlarged pyloris's!

Vomiting=dehydration
-metabolic alkalosis
-hypokalemia
-hemoconcentration (high hct)

RN Intervention for infant pt?
hydration d/t vomiting, intake and output, daily weight, urine specific gravity

Surgery neeeded

PS vs GER?
GER results in spitting formula with gastric juice (reflux)

507

Esopageal Atresia

-Esophagus ends in a blind pouch
-Saliva can't make it to stomach
-frothy mucus/cyanosis
-suction airway!

***No meconium because they never swallowed any amniotic fluid!
Fed with G-tube (straight into stomach)

508

Tracheoesophageal Fistula

Opening b/w trachea and esophagus
3 C's:
Coughing
Chocking
Cyanosis

-Potential for aspiration
-Pre-op, place infant on back with head and shoulders elevated to let secretions pool in lower esophagus.

-Common for moms with GI tract issues to have POLYHYDRAMIOS b/c baby never swallows amniotic fluid

509

Leukemia

-Most common form of childhood cancer
-cancer of blood forming tissue
-proliferation of immature WBC's (immunosuppressed)
--SO many WBC's no room for platelets or RBC's (thrombocytopenia and anemia)

ALL (acute lymphoid leukemia) +better prognosis
AML (acute myeloid leukemia)

510

Wilms tumor

Nephroblastoma
Found: KIDNEY or abdominal mass
-Swelling or non-tender mass on one side of abdomen
-abdominal pain, nausea/vomit

Wilms: DO NOT PALPAT ABDOMEN
-Gentle care with bathing or moving pt

511

Fontanelle Closure Times

Anterior: 7-18 months
Posterior: 1-3 months

512

Rheumatic Fever

-Inflammatory disease that occurs after an infection
-Group A B hemolitic streptococcus
Strep LOVES the heart and kidneys

Clinical manifestation: carditis!

Penicillin G or Erythromycin

513

Kawasaki Disease

Widespread inflammation of small and medium sized blood vessels.
-Coronary arteries most susceptible!

Treatment:
High dose of IV Immune G
Salicylate (ASA therapy)-aspirin
Bed rest

514

RN assessment of kids with cardiac dysfunction

-Nutritional status (failure to thrive, poor eight gain, fatigue with feeding, poor feeding habits)
-Color, chest deformities, unusual pulsations, resp effort, clubbing of fingers
-Behaviors (knee-chest position or squatting seen in some types of herat disease)
-Excessive sweating during feeding

515

CHF
Pediatric Pts

-Usually due to congenital heart defects

Early S/S:
increased pulse at rest/with slight exertion
increased RR
Scalp sweating (infants)
Fatigue
Sudden weight gain (>=1 lb/day is FLUID!)
--fluid retention, think heart problems first!

Tx:
Listen to lungs!!
Control room temp
Decrease heart workload (sit-up, rest, decrease stimuli)
Cool, humidified oxygen
Uninterrupted sleep
Feed q3hr
--20 min feedings
Digoxin
--Infants, hold if P<110, Children hold if P<70
--Normal dig level 0.8-2
Ace inhibitors- watch for cough!
Lasix

516

Patent Ductus Arteriosus

Hold between pulmonary Artery and Aorta.
Normal for fetus (O2 from placenta, not lungs). Should close after delivery.

MACHINERY LIKE MURMUR

517

Coarctation of Aorta

Narrowing of Aorta
-Difficulty for LV to pump
--Left sided HF

Dx?
Big difference in pulses and BP in UE's and LE's
Upper extremities much higher!

518

Tetrology of Fallot

PROVe

Pulmonary Stenosis
RV Hypertrophy
Overriding aorta
Ventricular Septal Defect

519

Transposition of the Great Vessels

Aorta Connected to the RA and RV
Pulmonary Artery connected to the LA and LV

2 separate sets of circulation.
Surgery required

520

Tonsillectomy

-Post op position: Side lying HOB elevated OR prone
-Don't give red or brown fluids (don't want anything confused with blood)
- hemorrhage? Frequent swallowing
-Hemorrhage risk for 10 days
-no milk
-avoid coughing, clearing throat, blowing nose
-avoid oral mouth rinses, gargling, vigorous tooth brushing

Common complains post-op?
Sore throat
Slight ear pain
Low grade fever (normal)
--spike=infection
Bad breath (old blood)

521

Intussusception

Sudden onset/episodes of pain
Currant jelly stool (maroon=blood and mucus)

522

Delegation

Designating tasks to others, but RN retains accountability

523

3 Rules of LPN Delegation

1. Only nursing care in stable situations
2. Orders not subject to change (do not delegate complex tasks)
3. Selected tasks in unstable situations


-Monitor pain and admin pain meds
-Titrate oxygen based on unit protocols
-Reinforce education
-Routine procedures (catheterization)
-Ostomy care
-Tube potency and enteral feedings
-specific assessments
-Monitor RN findings

524

UAP Delegation

Non-complex tasks:
***Allowed to pick up/return blood from blood bank!
-I and O
-Routine Vitals (not blood, dopamine, mag sulfate, nitro)
*before and after blood transfusion ok
-Basic Communication
-CPR (make sure doing it correctly)
-ID Risks
-Feeding pt (except stroke)
-Oral care (even on trach pt)
-ROM exercises
-Must teach to report back to RN on task/pt condition
*NOT PAIN
-CAN escort family to waiting area
-CAN report observations
-CAN empty, measure and record output from surgical drain
-NOTHING THAT STARTS WITH "MONITOR"
-CAN transport client to morgue

525

Ulcerative Colitis

Large intestine mucosal irritation
-bloody diarrhea

-high calorie/high protein diet
-multivitamins w/ calcium
->=2 L water/day
-Journal/Avoid dietary triggers
-Avoid caffeine, alcohol, tobacco

526

Acute Pancreatitis

Symptom Relief and Prevent Complications

NPO: food increases release of pancreatic enzymes.
-Use NG tube to suction gastric secretions

Pain: IV opioids

Fluid: aggressive IV fluid replacement to prevent hypovolemic shock

Positioning: flex trunk (Semi-fowlers) to decrease pressure on abdomen OR side-lying with head elevated to 45 degrees

527

Prevent Dumping Syndrome

Multiple small meals
Low CHO diet
Do not consume fluids and food at the same time (at least 30 min apart)

528

Narcissistic Personality Disorder

Fragile/Damaged Ego

Exhibit: grandiosity, need for admiration, lack of empathy

Project: superiority, uniqueness, independence (all hides emptiness)

Why? Need to regulate/maintain fragile self-esteem

529

Anemia in Pregnancy
Based on Trimester

1: Hgb <11
2: Hgb <10.5
3: Hgb <11

530

Circumcision Home Care

-Wash hands before
-Warm water, NO soap q4h
-Petroleum Jelly at diaper changes (q4h, 3-5 days)
-Yellow exudate normal (2-3 days)
-Expect 4-6 wet diapers first 24hrs
-Bleeding size of quarter ok

About procedure:
-was a sterile procedure in hospital
-Restrained in wrapped blanket or on special board to prevent injury
-sucrose solution offered for pain

Infection: red, odor, discharge

531

Mg Toxicity
Pre-eclampsia pt

Normal (non-prego) range 1.5-2.5 mEq/L

Therapeutic Mg level in pre-eclampsia pt to prevent sz:
4-7 mEq/L

Absent/diminished DTRs (normal=2+)
Respiratory depression
<30mL/hr UO
cardiac arrest

D/C infusion

Calcium glutinate (antidote) ONLY if cardiorespiratory compromise

532

SIDS Prevention

-Less than 1 yr supine to sleep
-Firm sleep surface
-Do not share bed with caregivers
-Avoid soft objects (stuffed animals, heavy blankets, pillows). Thin tucked blanket ok
-Avoid bumper crib pads
-Smoke-free environment
-Use pacifier when placing infant to sleep (>1 month)
-Breastfeeding and keeping up infant immunizations

533

Ventricular Septal Defect

many newborns asymptomatic
acyanotic defect

HARSH SYSTOLIC MURMUR
(systole and diastole)

534

Cystic Fibrosis Features

-meconium ileum (thick meconium/blockage at birth)
-Sinusitis
-Barrel Chest
-Pneumonia/bronchiectasis
-Cachexia (weakening/wasting of body d/t chronic illness)
-Biliary cirrhosis
-Pancreatic exocrine insufficiency
-CF-related diabetes
-Digital clubbing
-Inspissated (thicken/congeal) stools
-Absent vas deferens (infertile men)

535

Alpha-Adrenergic Blockers

Function, Use, Side Effects

-ZOSIN
(terazosin, prazosin, doxazosin)
Relaxes smooth
-bladder neck, prostate gland
-peripheral vasculature

Uses:
BPH
Hypertension

Side effects:
Orthostatic hypotension, falls/syncope, dizziness, ED

Misc:
-Take at bedtime to avoid orthostatic hypotension
-Do not take with -ENAFIL meds (sildenfail, vardenafil)
---also smooth muscle relaxing

536

Radiation Poisoning

Like chemo, affects rapidly proliferating cells first:

Oral mucosa
GI tract
Bone marrow

Phases:
Prodromal
Latent
Manifest
Recovery/Death

537

Neurogenic Shock

Disruptive (vasodilatory) Shock

Affect sympathetic nervous system (SNS), not parasympathetic nervous system (PNS)

MASSIVE VASODILATION
-hypotension
-bradycardia
-warm skin, not cool/clammy

538

Opioid Use Teaching

Common side effects:
-pruritus (antihistamines)
-flushing
-hypotension (fluids, rise slowly)
-nausea (antiemetics)
-constipation (no developed tolerance)

Constipation expected long-term side effect:
defecate when urge felt, 2-3L water daily, high-fiber diet, exercise),
stool softener (Decussate)
stool stimulant (Senna)

539

Common
Selective Serotonin Retake Inhibitors
SSRI's

citalopram (Celexa)
escitalopram (Lexapro)
fluoxetine (Prozac)
fluvoxamine (Luvox)
paroxetine (Paxil)
sertraline (Zoloft)

540

Common
Monoamine Oxidase Inhibitors
MAOI's

selegiline (Emsam)
isocarboxazid (Parplan)
phenelzine (Nardil)
tranylcypromine (Parnate)

541

Candida Albicans

*Oropharyngeal candidiasis/moniliasis*

Fungal infection
oral candidiasis (thrush)

White patches on oral mucosa, palate, tongue
Non-removable and tend to bleed when touched

At risk?
-Infants
-Pts with dentures
-immunosuppressed its (ex, taking corticosteroids, chemo/radiation, AIDS)

Treatment:
Anti fungal (nystatin)
Oral hygiene

542

Atrial Fibrillation Treatment Goals

Ventricular HR <100
Diltiazem (Ca Blocker)
Metoprolol
Digoxin

If you want to change rhythm to NSR:
amiodarone or ibutilide

543

Clonidine Patch

-change and rotate sites every 7 days
-dry hairless area on upper chest/arm
-no shaving before patch (razor burn)
-discard by folding sticky sides together
-1 patch at a time
-DO NOT stop using abruptly

544

Proof of repercussion after STEMI

Return of ST segment to baseline

-thrombolytic therapy can stop infarction process in STEMI
-given first 12 hrs of symptom onset

545

Infant Increased ICP S/S

fever
vomit
high-pitched cry
irritability

bulging fontanelle
"sunset eyes"
Prominent scalp veins
Increased head circumference

Potential bacterial meningitis

546

Dislodged Tracheostomy Tube
RN Action

-If mature (>7 days), insert new trach with obturator.

-If unable to: cover w/ sterile occlusive dressing (3 sides)
-ventilate w/ bag-valve mask over nose/mouth

547

IV Potassium Chloride
(KCl)

Central Venous Access Device (PICC, CVC):
Concentration: 20-40 mEq/100mL
Max Rate: 40 mEq/hr

Peripheral:
Concentration: 10 mEq/100mL

-KCl irritates vein
-May slow infusion rate to decrease discomfort.

548

Transfusion Reaction
RN Interventions

1. D/C immediately
2. Maintain IV access w/ NS and new tubing (prevent hypotension and vascular collapse)
3. Notify HCP and blood bank
4. Monitor Vitals
5. Recheck labels, #'s, blood type
6. Treat clients Sx based on HCP Rx
7. Collect blood/urine specimens to evaluate for hemolysis
8. Return blood/tubing set to blood bank
9. Documentation/paperwork

549

Autonomic dysreflexia

aka. Hyperreflexia
Spinal cord injuries >=T6
Exaggerated sympathetic nervous system response
HYPERTENSIVE EMERGENCY (uncontrolled HTN)
-Can lead to stroke or MI

Manifestations:
-acute onset of throbbing headache
-nausea, and blurred vision
-hypertension and bradycardia
-diaphoresis and skin flushing above the level of the injury

Triggers:
Bladder distension
Rectum distension
Pressure Ulcers

Treatment:
Check BP, Check bladder (cath), digital rectal exam, remove constrict clothing

550

Need for Cerebral Spine Stabilization

NSAIDS

N=neuro exam (numbness, decreased strength)

S=significant traumatic mechanism of injury

A=alertness

I=intoxication (decreased pain awareness)

D=distracting injury (not paying attention to spine)

S= spinal exam
(midline or point tenderness spine/neck)

551

Diabetic client wants to fast for religious reasons.
RN Action?

Assess for risk of adverse events!

-Clinical stability (comorbidities)
-glycemic control (hyper/hypo-glycemic episodes, medication regimen, knowledge, ability to self-monitor BG during fast)

552

Acute Pericarditis

Inflamed layers of pericardium rubbing against heart causing pain.
-ST Elevation in ALL EKG leads! (MI localized to leads being effected)
-CARDIAC TAMPONADE LETHAL COMPLICATION

-Worse with deep breathing/supine
-sit up and lean forward (fowlers or high fowlers)

553

Cholecystitis

Gallbladder inflammation

-Vomiting? NPO!
If in any major pain, NPO to decrease gall bladder stimulation.
-Low-grade fever, chills, nausea, vomit, anorexia
-RUQ pain (Murphy's sign) radiating to R shoulder or scapula
-Then deal with pain, fluid imbalance, and gastric decompression (NG Tube)
-FATTY FOODS 1-3 hrs pre-onset

Interventions:
Sims position
Deep breathing
Ambulation
Analgesics

554

Paralytic ileus

Temporary paralysis of portion of bowel.
Affects peristalsis and bowel motility

S/S: abdominal discomfort, distention, nausea/vomiting.

Risk Factors:
Abdominal surgery, perioperative meds (opioids, anesthesia, analgesics), immobility (stroke)

Treatment:
-NPO
-NG tube wall suction to decompress stomach
-F/E replacement to correct losses from NG suction
-Antiemetics (ondansetron, promethazine)

555

Epinephrine and Norepinephrine
vessel action

Adrenal Medulla
Fight/Flight Hormones

Acts directly on smooth muscles of blood vessels to CONSTRICT them

Norepi medication is a vasoconstrictor and vesicant that can cause tissue necrosis

556

What to avoid during therapeutic communication

"WHY" questions.
Viewed as critical, judgmental, and intrusive.

Voicing doubt ok.

557

Herbal supplements that increase risk for bleeding

-Gingko biloba (memory, claudation)
-Garlic
-Ginseng (improved mental performance)
-Ginger
-Feverfew

558

Intrapartum fetal HR monitoring mneumonic

VEAL CHOP
Variable-Cord compression

Early- Head compression

Accelerations- OK

Late- Placental insufficiency

559

Rotavirus

Contagious Virus
Leading cause of diarrhea in kids <5.
-Dehydration major risk!

Fecal-oral

Vaccination for kids less than 8 months old.

Contact w/ food, toys, diaper, and hands

*Hand washing
8

560

Heatstroke

-Temp >104F
-Hot, dry skin
-Hemodynamic instability (tachycardia, hypotension)
-AMS/neuro symptoms (confusion, lethargy, coma

Risk for permanent near injury or death directly related to duration.

ABC's and rapid cooling:
-cool water immersion
-cool IV fluids
Antipyretics INEFFECTIVE b/c unrelated to inflammatory process.

561

IV Potassium Chloride
KCl

Concentration: 40 mEq/L

Infusion Rate Max:
Central Line- 40 mEq/hr
Peripheral Line- 10 mEq/hr

Pain at peripheral site, slow IV infusion rate

562

Vitamin K Food

Do not eat with warfarin!

Greens!
green leafy veggies, cauliflower, broccoli, cabbage, lettuce, spinach, brussel sprouts

563

Do not eat with warfarin...

High vitamin K foods
Green tea, grapefruit juice, cranberry juice

564

Frostbite Treatment

-Do NOT massage/rub/squeeze
-Immerse in warm water (98.6-102.2)
-analgesia
-remove clothing/jewelry
-NO heavy blankets/clothing to prevent tissue sloughing
-While thawing, area may become edematous (ELEVATE) and blister
-Keep wounds open immediately after a water bath and allow them to dry before applying loose, non adherent, sterile dressings
-Monitor s/s compartment syndrome

565

Post-up naloxone

RN Action after:
1 dose given, 1 hr later decreased respiratory rate and low arousability

-Administer oxygen
-Assess respiratory rate
-Notify HCP
-Prepare 2nd dose!

Naloxone has shorter half life than most opioids. Wears off 1-2 hours.

566

Clozapine

Use?
Adverse effects?

-Atypical antipsychotic
-Treatment-resistant Schizophrenia
-AGRANULOCYTOSIS!
=Increased risk for infection (fever, sore throat, etc)

Monitor WBC (>3,500) count and ANC (>2000)
*Monitor WBC and ANC weekly*

Metabolic Syndrome
-weight gain
-hyperglycemia
-dyslipidema

-drooling, hypersalivation

Seizures

567

Glucocorticoid side effects

*Prednisone
*Methylprednisolone
*Dexamethasone

Side effects:
-increase in blood sugar
-fluid retention/increased hypertension
-stop suddenly can lead to adrenal crisis

568

1 oz converted to mL

1oz = 30mL

569

Caput succedaneum

CS=crosses suture

Edema/hematoma above periosteum that CROSSES suture lines

feels "spongy" and closes suture

*Resolves within first week

Expected finding

570

Cephalohematoma

Subperiosteal bleed that DOES NOT CROSS suture lines

Expected finding

571

Crutches Safety

-Clutter free (rugs)
-Look forward
-Use small backpack/bag to hold items to keep hands free
-Rubber/non-skid soled slippers/shoes
-Keep rubber tips dry

572

Measuring/Assessing JVD

-Bed at 45 degrees (semi-fowlers)
-Pulsation of neck veins

573

Refeeding Syndrome

Declines in PPM
Phosphorous (2.4-4.4)
Potassium (3.5-5)
Magnesium (1.5-2.5)

Food=insulin=shift into cell. Hypophosphatemia= muscleweakness= resp failure

Other:
fluid overload, Na retention, hyperglycemia, thiamine deficiency

Actions to prevent refeeding syndrome include the following:
-Obtaining baseline electrolytes
-Initiating nutrition support cautiously with hypocaloric feedings
-Closely monitoring electrolytes
-Increasing caloric intake gradually

574

Splenectomy lifelong risk for...

RAPID SEPSIS!
Even low-grade fever should be taken seriously with these clients.

A lot of vaccines:
pneumococcus, meningococcus, haemophilus influenzae type B

575

Cellulitis

Common skin bacterial infection

IV antibiotics in clients with DM

576

RN Plan of Care for
Pertussis Infection

-Droplet precautions
-Monitor signs airway obstruction
-Small amounts of fluid frequently
-Oral antibiotics
-Supportive measures (humidified oxygen)
-cough >2 wks
->1 wk paroxysms of cough, inspiratory whooping sound, and posttussive vomiting

577

Acute appendicitis

Appendix

-ABDOMINAL pain (belly button to RLQ)
-POINT of McBurney's (most pain, b/w belly button and hip bone)
-POOR appetite
-ELEVATED temp
-NAUSEA/vomiting
-DESIRE to be in fetal position/relieve pain
-INCREASED WBC, inability to pass gas or have BM
-rebound tenderness RLQ

-Surgery required in first 24 hrs

578

Vaso-occlusive Crisis

Pain crisis in Sickle Cell Disease

Elevated reticulocytes
Elevated bilirubin
Anemia

NOT RELATED: rbc's, high k.

579

Psoriasis
Look
Management

Chronic autoimmune disease-rapid turnover of epidermal cells.
-silver plaques on reddened skin
-NO CURE

Manage:
-avoid triggers (stress, trauma, infection)
-topical therapy (corticosteroids, moisturizers)
-phototherapy/sunlight
-systemic medications, cytotoxic (methotrexate) and biologic (infliximab) agents

580

Post-op Chest Tube
Drainage

-Excessive drainage (>100 mL/hr)
-Air/fluid in chest (diminished breath sounds)
-pain
-infection at drainage site
-Excess drainage of frank red blood = hemorrhage must be managed immediately
-Assess every hr for first 8 hrs
-Then every 8 hours until removed

581

Cyclobenzaprine

Flexural
Common centrally acting muscle relaxant:

For muscle spasticity, muscle rigidity, acute/chronic muscle pain/injury.

Metabolized by LIVER.
Toxicity with liver disease (hepatitis) and increased CNS depression

582

Cognitive Behavioral Therapy

Maladaptive reactions to stress, anxiety, and conflict:

CBT has 5 basic components:
-Education about disorder
-Self-observation and monitoring -anxiety, identify triggers, and assess the severity
-Physical control strategies – deep breathing and muscle relaxation exercises
-Cognitive restructuring – learning new ways to reframe thinking patterns
-Behavioral strategies – focusing on situations that cause anxiety and practicing new coping behaviors, desensitization to anxiety-provoking situations or events

NOT: interpersonal psychotherapy, NOT psychodynamic therapy

583

Calcium Channel Blockers

-dipine
Very Nice Drugs
Verapamil, Nifedipine, Diltiazem

Blocks Ca access to cells causing:
*Decreased heart contractility/rate
*Decreased demand for oxygen
*Decreases PVR
*Relaxation of vascular smooth muscles

Uses: angina, HTN, dysrhythmias (verapamil, dilt)

Adverse effects:
Dizziness
Peripheral edema
Constipation
Orthostatic hypotension

584

Dental avulsion

Tooth separated from mouth.
If permanent tooth- DENTAL EMERGENCY!

Re-implantation in 15 min reestablishes blood supply. Tooth might survive.
Can put tooth in:
cold milk, sterile saline, Hanks balanced salt solution.

NOT hypotonic solution!

585

Hypoglycemia S/S

BG <70
Epi released!
Trembling/Shakiness
Palpitations
Anxiety/arousal
Restlessness
Diaphoresis/pallor

Prolonged Hypoglycemia:
neuro symptoms!
confusion
seizures
coma

586

Receptive Aphasia
Intervention

Impairment or loss of language comprehension (speech, reading)

-Ask short, simple, "yes" "no" questions
-Use gestures or pictures to demonstrate activities
-Remain patient and calm, allowing pt to understand each instruction
-eye contact

do NOT:
raise voice. Hearing isn't the issue

587

Peptic Ulcer Disease Treatment
*Types of Ulcers

"Triple Drug Therapy" 14 days
Amoxicillin, Clarithromycin, Omeprazole
-Avoid triggers
-Stop smoking, drinking

Duodenal Ulcers: Pain 2-3 hrs post meals
Food might decrease pain

Gastric Ulcers: aPain 30 min- 1 hr after meals
Eating increases pain

Stress ulcers- Cushing's ulcers (brain injury), Curling's Ulcer (extensive burns)

588

Emergency Drugs to LEAN on

Lidocaine (V-arrhythmias, MI's)
Epinephrine
Atropine (treats brady)
Narcan (opioid reversal)

589

IDEA for slow HR and BP

Isoproternol- relaxes BV and increases cardiac pump efficiency
Dopamine- Increases pump strength
Epinephrine- constricts peripheral BVs to shunt blood to heart and brain
Atropine- anticholinergic- treats symptomatic brady

590

ABCDE for atrial arrhythmias

Anticoagulants
Beta Blockers (slow HR)
Ca Channel Blockers (slow HR, contractility, smooth muscle relaxation)
Digoxin (stronger HR)
Electrocardioversion

591

Anticholinergic drugs

Cause decrease in parasympathetic effects!
S/S-Same as sympathetic fight/flight

Decreased smooth muscle spasms
Decreased digestion
Pupil dilation
Increased secretions
Increased HR
Airway relax

Atropine, Ipratropium, Benztropine, Scopolamine, Oxybutynin
Uses: AV blocks, mydriasis for retinal exams, Increased HR for symptomatic bradycardia

592

Death Rattle

Actively dying
Unable to manage airway/clear secretions

Give anticholinergics to dry secretions!
Atropine drops
Scopolamine patch

593

Small Bowel Obstruction
S/S

Treatment

-rapid onset nausea/vomit
-colicky, intermittent abd pain
-distension

Treatment:
NPO
NG tube
IV fluids
Pain treatment

594

Large Bowel Obstruction
S/S

-gradual onset of symptoms
-cramping/abd pain
-distension
-ABSOLUTE constipation
-lack of flatus

595

Meds Pregos CANNOT have

Ace inhibitors
doxycycline
isotretinoin (accutane)

NSAIDS (aspirin, ibuprofen-Motrin/Advil)
Thalidomide

596

Fondaparinux

Unfractioned heparin

Do not give until >6 hrs post op
-same rule for LMW heparin

597

Sjogren's Syndrome

-Auto immune disorder
-WBC's attack moisture-producing exocrine glands

-Salivary gland decrease: Xerostomia (dry mouth)

-Lacrimal gland decrease: Xerophthalmia (dry eyes)

Dry skin (itchiness, rash), throat/bronchi (dry cough)

***Avoid decongestants! Further dryness
*Avoid oral irritants (coffee, alcohol, nicotine, acidic drinks)

Treatment:
eye drops, SF candy, lubricant, frequent dental exams, lukewarm showers/mild soap, avoid decongestants (oxymetazoline, phenylephrine, pseudo ephedrine)

598

Dislodged CVC
RN action

-Oxygen non-rebreather
-Occlusive dressing
-Monitor VS/Resp effort
-Notify HCP
-Left Lateral Trendelenburg

599

Inserting NG Tube for gastric decompression

1. Hand hygiene and apply clean gloves (not sterile)
2. Pt in high Fowler's position
3.Assess nares and oral cavity and select naris
4. Measure (nose, ear, typhoid) and mark the tube
5.Curve 4-6" tube around index finger and release
6.Lubricate end of tube with water-soluble jelly
7. Instruct client to extend neck back slightly
8. Gently insert tube just past nasopharynx, aiming tip downward
9. Rotate tube slightly if resistance is met, allowing rest periods for client
10. Continue insertion until just above oropharynx
11. Ask client to flex head forward and swallow small sips of water (or dry if NPO)
12. Advance tube to marked point
13. Verify tube placement and anchor - use agency policy and procedure to verify placement by anchoring tube in place and obtaining an abdominal x-ray.

-Aspirating gastric contents and testing the pH may also give an indication of placement (pH should be 5.5 or below).
-Auscultation of inserted air is acceptable for confirming tube placement initially, but is not definitive as it is not an evidence-based method.
-Nothing may be administered through the tube until x-ray confirmation is obtained, or this may cause aspiration.

600

Gastric Lavage

-Use large-bore (36-42 french) orogastric tube
-Removes ingested toxins/irrigates stomach
-Intubation/suction supplies ready in case of emergency
-pt on their side or with head of bed elevated
-initiate within 1 hr of OD

Activated charcoal admin is standard treatment for OD, but ineffective for lithium, iron, alcohol

601

PTSD communication

They believe they are responsible/to blame. Will experience guilt/shame.

Convey that what happened was not their fault.

602

Disulfiram

Antabuse
Aversion therapy-alcohol abstinence

If alcohol consumed, pt may experience headache, intense nausea/vomit, flushed skin, sweating, dyspnea, confusion, tacky, hypotension).

Large amount can be FATAL

Hidden alcohols in:
-liquid cold/cough meds
-aftershave, lotions, colognes, mouthwashes
-foods such as sauces, vinegars, flavor extracts

Abstain from alcohol for 2 weeks after last dose b/c run could still occur

Wear med bracelet to let others know you're on disulfiram therapy

603

Cryptorchidism

undescended testicle

-If at birth, not concerning. Most descend spontaneously by age 6 months

604

Concerning fetal abnormalities at birth

Cranial nerve abnormalities.
Ex. ptosis (drooping of eyelid below level of pupil)

Normal: rales (crackles) for a few hrs after birth.
Dull percussion over bladder (full bladder)

605

HELLP Syndrome

Severe form of preeclampsia:

Hemolysis
Elevated Liver enzymes
Low Platelet count

Presentation:
(sometimes non-specific)
RUQ pain
nausea
vomit
malaise

If not treated immediately could lead to placental abruption, stroke, and death

606

Cystitis

-Most commonly acquired UTI (e.coli)
-Lower UT
-Bladder (mucosa) inflammation!

S/S:
-burning urination (dysuria)
-urinary frequency
-urinary urgency
-hematuria
-suprapubic discomfort

607

Pyelonephritis

Kidney infection (e.coli)!
Can ascend from bladder.
-nausea
-vomit
-FEVER WITH CHILLS
-FLANK PAIN EXTENDING TOWARDS UMBILICUS
(costovertebral angle tenderness)

608

Huff coughing
Why?
How?

COPD
-need to learn to expectorate mucus without high-pressure coughs (incapable)

1. Position upright
2. Inhale through the nose using abdominal breathing and prolong the exhalation through pursed lips for 3 breaths – deflates excess air from lungs
3. Hold breath for 2–3 seconds following an inhalation, keeping the throat open
4. Deeply inhale and, while leaning forward, force the breath out gently using the abdominal muscles while making a "ha" sound (huff cough); repeat 2 more times (eg, "ha, ha, ha") – keeps airways open while moving secretions up and out of the lungs.
5. Inhale deeply using abdominal breathing and give one forced huff cough – the last, increased force ("ha") usually results in mucus being expectorated from the larger airways.

609

Transplant patients highly...

IMMUNOSUPPRESSED!
On strong immunosuppressant meds.
Infection can be rapidly progressing and be FATAL.
Low grade feel is a priority.

610

Thiazolidinediones

rosiGLITAZONE
pioGLITAZONE
*Treat type 2 diabetes*
increase insulin sensitivity

-Can worsen heart failure by causing fluid retention
-Risk:bladder cancer
-risk: heart events (MI)

-low risk for hypoglycemia

NO retinopathy risk related to the med.

611

Coronary Arteriogram

Angiogram

-invasive diagnostic study coronary arteries, heart chambers, function

-NPO 6-12 hrs before
-warm and flushed when dye injected
-may have to lie flat for several hours to ensure hemostatis in artery that was cannulated for procedure.
-NOT general anesthesia
-can usually go home that day

612

Neonatal heel stick

-medial or lateral side of outer aspect of heel
-warm heel for several minutes with warm towel
-sucrose and nonnutritive sucking
-cleanse with alcohol
-automatic lancet

Acceptable alternate method: venipuncture (draw blood from vein)
-less painful
-fewer punctures for more larger sample

613

Fecal incontinence
Types

aka. encopresis, soiling
>4 years old

Functional: retentive
-constipated for days, painful stool, repeat cycle (think of parents that only feed their kids candy)
-reward system to encourage child's involvement in treatment

Psychosocial (non retentive)- cannot control feces

614

Adverse events

Error types

-Injuries caused by medical management, NOT client's underlying condition.

Error types:
-diagnostic
-treatment
-preventive
-other (failure to communicate, equipment failure system failure

615

Cerebral aneurysms

Asymptomatic bless they rupture
"silent killers"

"The worst headache of my life"

616

Long bone fractures

Femur
Humorous
Tibia

POTENTIAL FAT EMBOLUS!
Travel to lungs, skin, and brain
AMS= blocked blood vessels in brain!
Lungs=respiratory distress

Hallmark sign: PETECHIA-pin sized red/purple spots
small vessels clotting.
Chest, axillae, soft palate

617

Hyperkalemia Med Admin

If peaked T waves:
1) calcium glutinate
2) insulin/dextrose

If no peaked T waves, start insulin/dextrose

618

Levetiracetam

Keppra
Anticonvulsant for seizure disorders

Depresses CNS:
drowsiness, somnolence, fatigue AS CLIENTS ADJUST to meds
-Typically improves in 4-6 wks

Risks needing immediate attention:
-increased anxiety, depression, SI
-Stevens-Johnson syndrome (blistering skin)

619

Driving for patients with seizures

Avoid driving or operating heavy machinery until they have permission from their HCP

Usually requirements from department of transportation (sz free for certain period of time)

620

Stevens-Johnson syndrome

Rare, but life-threatening blistering reaction of skin.
MEDICAL EMERGENCY!

1. flu-like symptoms
2. painful rash
3. blistering

Other:
fever, malaise, coughing, eye redness, itching, mouth ulcer, sensitivity to light, sore throat, selling, peeling, rash of purplish or red spots

621

Acanthosis nigricans

-Skin condition
-Usually obesity and diabetes

Velvet-like patches of darkened, thick skin

Usually around back of neck, groin, and armpits

622

Respiratory Depression r/t Opioid use for Analgesia
RISK FACTORS

-the elderly
-underlying pulmonary disease
-hx of snoring (w or w/o apnea)
-obesity
-smoking (>20-pack-year hx)
-the opiate naive
-24 hrs post-op

623

When to see HCP for diarrhea

>48 hrs
OR
accompanied by fever or bloody stools

Diarrhea usually self-limiting (48hrs)

624

aPTT time

30-40 seconds

If on anticoag therapy:
46-70 seconds

625

LPN Scope

-Monitoring RN findings
-Reinforce education
-Routine sterile procedures (eg. catheterization)
-Most med admin
-Ostomy care
-Tube potency and enteral feeding
-focused assessments
-collection of specimens
-Stable clients

-measure stockings or devices/choose appropriate device

626

Medically emancipated minor

Minors can provide own consent.

-Emergency care
-STI
-Substance abuse
-Prego care
-Contraception


Regular Emancipated minor:
homeless, parent, married, military, financially independent, HS grad

627

Reaction Formation

Behaving in a manner or expressing a feeling opposite of ones true feelings

Ex. A parent who is resentful of an "unplanned" child become overprotective

628

Sublimation

Transforming unacceptable thoughts or needs into acceptable actions.

Ex. Aggressive person becomes star boxer.

629

Drugs to lower Ventricular Rate

DILTiazem
MetroprOLOL
DIGoxin

630

Target BP and HbA1c for Diabetic Pts

<140/90
<7%

631

Expected findings in pneumonia

fever
chills
fatigue
crackles
sputum production

632

DVT Risk Factors

-Trauma
-Major Surgery
-Prolonged immobilization
-Oral contraceptives
-Underlying malignancy
-Smoking
-Old age
-Obesity and varicose veins
-Myeloproliferative disorders (increased blood viscosity)

633

Retinoblastoma

Retinal Tumor
-usually dx kids <2

White "glow" of one or both pupil(s) (leukocornia)
-white instead of red in photos

Strabismus 2nd most common sign
-misalignment of the eyes

634

IV Opioid Analgesics

Admin and Side Effects

Hydromorphone/Morphine

-SLOWLY Over 2-3 minutes

Sedation
Resp depression
Hypotension
Constipation

REASSESS during opioid's peak effect!
15-30 min for hydromorphone

635

Sedation Level Scale

S-sleepy
1- awake, alert
2-slightly drowsy, easy to arouse
3- falls asleep during conversation (unacceptable)
4-somnolent (stop sedation, maybe use naloxone)

636

Iron Supplement

NO MILK

Better on empty stomach
Vitamin C increases absorption (citrus fruits/juices)

637

Warning signs of cancer

CAUTION
-Change in bowel or bladder habits
-A sore that does not heal
-Unusual bleeding/discharge
-Thickening or lump
-Ingestion or difficulty swallowing
-Obvious change in wart/mole
-Nagging cough/hoarseness

638

Acceptable Residual Urine

<100mL

Report amounts >100mL to HCP

639

Parkinson's Disease

-Trembling of extremities
-Resting tremor
-Stooped posture
-Rigidity
-Masked facial expression
-Forward tilt of trunk
-Reduced arm swinging
-Slightly flexed hips/knees
-Shuffling, short gait

640

Serotonin Syndrome

*Potentially lethal
*OD Antidepressants

-Mental status change (anxiety, agitation, disorientation)
-Autonomic dysregulation (hyperthermia, diaphoresis, tachy/htn, mydriasis)
-Neuromuscular hyperactivity (tremor, muscle rigidity, clonus, hyperfreflexia, diarrhea, hyperactive bowel)

641

Peripheral Artery Disease

Risk Factors:
Smoking
DM
Hyperlipidemia
Smoking

Pain in LE's with movement/exercise d/t ischemia
At rest, might experience burning, aching, numbness

642

Saw palmetto

Natural Herb:
BPH

643

Hawthorn extract

Natural Herb:
Heart failure

approved in Germany

644

Major depressive disorder
2 key clinical features

aka: unipolar depression

1. Depressed Mood
2. Loss of interest or pleasure (anhedonia)

1 sx above for >=2 weeks

Other: SIGECAPS
Sleep (up/down)
Interest deficit (anhedonia)
Guilt
Energy deficit
Concentration deficit
Appetite (up/down)
Psychomotor retardation/agitation
Suicidality

645

Testicular torsion

Emergency Condition
Stopped blood flow to testis (scrotum), hehe :D

-Testicle rotates/twists the spermatic cord
-swelling/severe pain
-testicular ischemia and necrosis
-Small treatment window! 4-6 hrs
--use ultrasound to dx
-Emergency surgery

Potential testicle death!

646

Severe asthma exacerbation characteristics and treatment

-Tachycardia >120
-Tachypnea >30
-O2 Sat <90RA
-Accessory muscle use
-Peak expiatory flow
-<40% predicted or best (<150 L/min)

1. Oxygen
2. High-dose inhaled short acting beta agonist (ALBUTEROL) and anticholinergic agent (IPRATROPIUM) neb treatment q20min
3. Systemic corticosteroids (Solu-Medrol)

647

Wound Culture procedure

1. Hand hygiene, gloves, remove old dressing, d/c gloves

2. hands again, STERILE gloves, assess wound.
Cleanse with normal saline. Remove gloves

3. hands again, CLEAN gloves, swab from center to outer margin.
AVOID contact with skin at wound edge.

4. swab in STERILE specimen container.

5. Apply topical med, BACITRACIN, after culture. Apply new dressing

6. remove gloves, hand hygiene, label specimen, document

648

Gout
What is it?
Suggested lifestyle mods.

hyperuricemia
Urate crystal deposits (aka, TOPHI) in joints

Modifications:
-weight loss
-Increased fluids
-LOW-PURINE DIET
***avoid organ meats
***avoid certain seafood (sardines/shellfish)
-Limit alcohol, especially beer
-Healthy, Low-fat diet
-Low-fat dairy products goos source of protein :)

649

Normal ICP

ICP while doing RN interventions on pt with brain injury

Normal: 7-15 mmHg

Max for working on pt with brain injury: 25mmHg
Should return to baseline within a few minutes

650

RN interventions to control ICP

-HOB 30 degrees, maintain neutral alignment
-Stool softeners
-manage pain well
-calm environment
-adequate O2
-Hyperventilate and pre oxygenate before suction
-avoid clustering care

651

Hypoxic client:
Post op care after general anesthesia

Obese person probably has obstruction (use of accessory muscles, snoring, decreased O2, cyanosis)


Head tilt and chin lift to open occluded airway

652

RN interventions for a newborn immediately after delivery

1. Standard precautions (gloves)
2. Maintain clear airway
*pharynx first, nares second*
3. Thermoregulation (97.5-99)
4. IM vitamin K injection in vastus laterals within 6 hrs (mid anterior lateral thigh)
7. Ophthalmic ointment for gonorrhoeae legally required (within 1 hr)
8. Initial bath! Remove blood, bodily fluids, or meconium.
Leave vernix caseosa (waxy white coating)

653

Suspected urinary retention

Opioids, anticholinergic meds, tricyclic antidepressants

Increase bladder sphincter tone and/or relax bladder muscle

RN intervention:
palpate suprapubic area

654

Shock Continuum: Stages of Shock

I. Initial
-inadequate O2 to supply the demand.
-Anaerobic metabolism.
-No recognizable S/S

II. Compensatory
ex. urinary retention to maintain fluid volume.
-Tachycardia to maintain cardiac output and O2 demand.

III. Progressive
-Failure of compensatory
-cold and clammy skin

IV. Irreversible

655

Normal urine output

0.5-1 mL/kg/hr
OR
>30mL/hr

656

ALS

Amyotrophic Lateral Sclerosis
-progressive loss of motor neurons in brainstem and spinal cord

ONLY MED:
RILUZOLE
*slows progression*
Prolongs life 3-6 months

Client Care Focus:
Respiratory function, adequate nutrition, quality of life
*Dysarthria=worsening ability to speak. May also have dysphagia and rest distress

No cure
Death usually in 5 years

657

External Fixation

Stabilizes bone with inserted metal pins through skin into bone.
Metal pins attached to rod outside of skin.

S/S infection:
low-grade fever
drainage
pain
redness
swelling
***immediate treatment

Could lead to osteomyelitis!!!

658

Chronic subdural hematoma

-Bleeding into subdural space.
-Can occur several weeks to months following a mild head trauma

-Elderly on anticoags are at high risk.
-Elderly also at risk because of falls.

Manifestations:
headache
gait disturbance
memory loss
decreased LOC

*Investigate Immediately!*

659

Expected findings in neonate 1-3 hrs post-delivery

-Blood glucose above 40, but below 70.
(normal 70-100)

-Resp rate 30-60
Might be sightly irregular, diaphragmatic, and shallow

-Milia (white papule) on nose and chin. Resolve without treatment within several weeks



Abnormal:
-holosystolic murmur=VSD

660

Down Syndrome

Trisomy 21

single transverse crease across palm

small and low-set ears

flat nose bridge

protruding tongue

hypotonia (floppy muscle tone) at birth

661

Total joint replacement surgery contraindications

Recent/current infection
ex. burning on urination

Report to HCP immediately

662

Cirrhotic Liver
Blood Test Values

-Elevated bilirubin (jaundice)

-Elevated PT INR, aPTT
(Liver makes coagulation factors)

-Ammonia (usually converted to urea in liver and excreted by kidney).
-increases and crosses blood-brain barrier leading to *hepatic encephalopathy*

-Decreased albumin
Liver unable to synthesize protein (albumin)

-Decreased sodium
With 3rd spacing r/t low albumin, kidney tries to conserve sodium and water. Na gets diluted!

663

Endotracheal tube suctioning

1. gloves
2. suction oropharynx/oral care
3. wall suction <120 mmHg
4. hyper oxygenate
5. advance cath until resistance met
6. remove with intermittent suction <10 seconds
7. evaluate tolerance. Repeat 1-2 times
8. resume oxygenation/vent settings

664

Risk factors and symptoms for pelvic inflammatory disease (PID)

*leading cause of ectopic pregnancy and infertility*

-Multiple sexual partners
-Hx of chlamydia or gonorrhea
-Hx of PID
-Partner with STI
-Lack of consistent barrier contraception use (no condoms)
-Age 15-25

Symptoms:
-pelvic/lower and pain -menstrual irregularities
-increased menstrual cramps
-painful intercourse
-fever
-abnormal vag discharge

665

Prevent Post-Op Pneumonia

-Adequate pain control
-Ambulate within 8 hrs if possible
-Coughing with splinting q1hr
-Deep breathing/incentive spirometer every hr
-Fowler's position (45-60 degrees)
-Turn/reposition q2hr
-Swab mouth with chlorhexidine swabs q12hr
-hand hygiene!

666

TB associated S/S

Tb in any location:
-Night sweats
-Low grade fever
-Anorexia and Weight loss
-Fatigue

Pulmonary TB:
-cough
-purulent or blood-tinged sputum
-SOB

667

Splenic sequestration crisis

Finding: rapidly enlarging spleen

Life Threatening!
Leads to hypovolemia (hypotensive) shock.

Occurs when a large number of "sickled" cells get trapped in spleen causing splenomegaly.

668

Vegan Diet Complications

Risk for Low:
*Protein
*Calories
*Calcium (vitamins will be needed)
*Vitamin D
*Iron (fortified cereals. increase absorption with Vit C)
* Vitamin B12 (cobalamin)
-only in animal proteins

At risk for megaloblastic anemia and neurological manifestations

Cobalamin (Vit B12) deficiency affects entire nervous system from peripheral nerves to spinal cord and brain.

"hands and feet get tingly sensation"

669

Progestin-only Pills
(POPs)

-oral contraction
-thicken cervical mucus (hinders sperm motility)
-thins endometrium (hinders implantation)

-Same time everyday
->=3 hrs late, barrier method advised until pill correctly taken for 2 days
-additional POP taken if diarrhea or vomit occurs within 3 hrs of last dose
-No inactive pills in POP pack. No break from hormone to menstruate
-breakthrough bleeding commonly reported
-Low cardiovascular risk profile, so lower risk for clots

670

Therapeutic hypothermia

-Cardiac arrest
-Comatose
OR
-Do not follow commands after resuscitation

-Neurologic injury most common cause of death in V-fib and pulseless V-tach.
**this improves neurologic outcomes and decreases mortality

-induce within 6 hrs of arrest
-maintain for 24 hrs
-89.6-93.2 degrees
-cooling blankets; ice placed in groin, axillae, sides of neck; cold IV fluids

671

Carboxyhemoglobin Level

Carbon monoxide

Normal: <5%

Smokers: <10%

Pulse oximeter can't detect difference between O2 and CO.

CO poisoning:
headache, dizzy, fatigue, nausea, dyspnea

672

Colorectal Cancer S/S

-blood in stool
-abd discomfort
-anemia d/t intestinal bleeding
-change in bowel habits
-unexplained weight loss

>50 routine colorectal cancer screening

673

Seizure manifestation Phases

1. prodromal phase: warning signs
2. aural phase: visual/sensory changes
3. Ictal phase: SEIZURE!
4. Postictal pose: confusion/recovery

674

Pleural Effusion
What is it?
S/S

Abnormal collection of fluid (>15mL) in pleural space.
Prevents lung from fully expanding resulting in:
-Atelectasis (collapsed/partially collapsed)
-Decreased lung volume
-ineffective gas exchange

S/S
Dyspnea
Pain with respiration’s
Diminished breath sounds
Dullness to perfusion over affected area

675

Erratic plethysmograph waveform.
First action?

Check/Asses the patient's O2/perfusion status and assess for motion artifact.

676

Bacterial meningitis care

-Droplet isolation (surgical mask, private room, pt masked during transport)
-Reduced stimulus (quiet, dimly lit, coo temp)
-HOB 10-30 degrees
-Seizure precautions (padded bed rails, O2 and suction at bedside)

677

Pincer Grasp Age

-Thumb and forefinger movement
**develops at 8-10 months**

Can pick up small finger foods

678

When to introduce allergenic foods to babies

4-6 months of age

Examples?
Eggs, fish, peanut products

679

Agoraphobia

fear and anxiety about being in (or anticipating) certain situations or physical spaces.

Examples:
-Outside the home alone
-In a crowd or standing in line
-Traveling in a bus, train, car, ship, or airplane
-On a bridge or in a tunnel
-Open spaces (eg, parking lots, marketplaces)
-Enclosed spaces (eg, theaters, concert halls, stores)

680

Renal Calculi Pain

Excruciating, sharp, and stabbing

Unable to find comfortable position

Pain radiates down to groin as stone travels

681

ATK amputation post op

Above-the-knee amputation

-Residual limb should not be elevated!
*Figure eight compression bandage*
-Prone 30 min 3-4x/day
-abductor pillow
-no bending at hip more than 90 degrees
-no crossing legs

682

When to hold insulin

Possibly when client is NPO

Glucose below 70 mg/dL

683

Alzheimer's Safety Mods

-Arrange furniture to allow for free movement

-Frequently used items in easy reach

-Lock on stairwells/doors that lead outside (above or below eye level)

-motion sensor/alarm when someone tries to exit

-Stop sign on door exits

-childproof doorknob covers

-Label doors to bathroom

-Provide nightlight to prevent falls, aid in orientation, and decrease illusions

684

Vaginal hematoma
Cause
S/S

-formed when trauma to perineum (forceps, vacuum, episiotomy)

-persistent, severe vaginal pain

-feeling of fullness

-Uterine funds firm/midline

-Unchanged vaginal bleeding

685

Post-mortem care

-Family participation ok
-maintain standard/isolation precautions until TOD
-Remove tubes/dressings (unless autopsy or organ harvest pending)
-Straighten and wash the body
-Change the linens
-Leave dentures in place or replace them
-Fold towel under chin to keep jaw closed
-Pad under perineum (leaking stool/urine)
-Place a pillow under the head (prevent blood from pooling and discoloring)
-Remove equipment and soiled linens from the room
-Give client's belongings to a family member or sent with the body

686

Don PPE Order

Hand hygiene

Gown

Mask or Respirator

Goggles or Face Shield

Gloves

687

Frontal Lobe

Parietal Lobe

Occipital Lobe

Temporal Lobe

Medulla Oblongata

Frontal: personality and behavior
Damage=Broca/expressive aphasia

Parietal: somatic and sensory input

Occipital: Vision

Temporal: Auditory input and past experiences
Damage to left side =Wernicke/receptive aphasia

Medulla Oblongata: rate and depth of respirations

688

Normal aPTT

Anticoagulant Therapeutic aPTT

25-35 seconds

1.5-2x greater if on heparin

46-70 seconds

689

Pleural Effusion
What is it?
S/S

An abnormal collection of fluid (>15mL) in the pleural space.
Prevents full lung expansion resulting in:
-Decreased lung volume
-atelectasis
-ineffective gas exchange

S/S
-dyspnea
-pain w/ respirations
-diminished breath sounds
-dullness to percussion (over affected area)

690

Nasal Spray Admin

1. High Fowler's position with head slightly tilted forward
2. Insert the nasal spray nozzle into an open nostril, occluding the other nostril with a finger
3. Point the nasal spray tip toward the side and away from the center of the nose
4. Spray the medication into the nose while inhaling deeply
5. Remove the nozzle from the nose and breathe through the mouth
6. Repeat the above steps for the other nostril
7. Blot a runny nose with a facial tissue, but avoid blowing the nose for several minutes after instillation

691

3 signs of worsening asthma attack.

1. pulses paradoxes
-Drop of bp on inspiration

2. silent chest
-airway is so closed there's no wheezing!

3. increasing CO2 despite tachypnea
-not getting anything out of lungs

Intubate and Ventilate!

692

Normal Newborn Serum Glucose

40-60 mg/dL

hypoglycemia=jitteriness or tremors
FEED THAT BABY ASAP!

If you give baby glucose, huge amount of insulin released and rebound hypoglycemia would occur.

693

Left-to-Right-Sided heart shunt

Cause blood to shunt from high pressure LEFT to low pressure RIGHT
*patent ductus arterioles, atrial septal defect, VSD*

Results in pulmonary connection (increased work breathing, decreased lung compliance).

*ACYANOTIC DEFECTS
-tachypnea
-tachycardia, even at rest
-diaphoresis during feeding/exertion
-heart murmur
-signs of congestive heart failure
-increased metabolic rate/poor wt gain

694

Right-to-Left-Sided defects

CYANOTIC DEFECTS

Impede pulmonary blood flow
-TOF
-Transposition of the great vessels

-need immediate attention after birth

695

Aphasia
2 types

Impaired communication r/t neuro condition

1. Receptive aphasia:
-impaired comprehension of speech and writing

2. Expressive aphasia:
-difficulty with word choice


Dysarthria- weakness of muscles used for speech
Pronunciation/articulation affected (mumble, lisp)

696

Apraxia

Loss of ability to perform learned movements

697

Scleroderma

Overproduction of collagen causing tightening and hardening of skin and connective tissue.

*Progressive with no cure*
-renal crisis
-malignant htn

698

Sepsis neonatorum

Medical Emergency
Baby Sepsis

-Increased sleepiness (lethargy)
-Poor feeding
-Increased/decreased temp

Full septic workup.
-Broad-spectrum antibiotics immediately after blood, urine, and CSF

699

Tinea Corporis

Ring Worm
aka: dermatophytosis

Fungal infection
Transmitted from 1 person to another or from animal to humans

700

Methylphenidate administration

For ADHD

-30-45 min before meals
-Dose start low and titrate up
-2-3 doses daily
-Monitor closely
-Last dose NO LATER than 1800

701

Obstructive sleep apnea

Symptoms
Interventions

Symptoms:
sleep disturbance, snoring, morning headache, daytime sleepiness, difficulty concentrating, forgetfulness, mood changes, depression

Interventions:
-Continuous positive airway pressure device
-Limit alcohol intake
-Weight loss/exercise
-Avoid sedating medications (bento's, antihistamines, opiates, sedating antidepressants)

DO NOT:
-nap during the day
-eat before bed
-take sedatives

702

Creatinine clearance test

24-hour urine collection

Blood draw

703

Laryngeal stridor
What is it?
RN action?

high-pitched, vibratory, harsh sound on inspiration or expiration

INDICATES PARTIAL AIRWAY OBSTRUCTION!

RN action:
-suction devices
-oxygen
-tracheosomy tray ready

704

Potassium-sparing diuretics used with thiazides.

Alone outcome
Together outcome

K-sparing:
spironolactone, amiloride, triamterene eplerenone
-Generally weak diuretics and antihypertensives

-Useful when combined with thiazide to reduce K loss!
-Normal K (3.5-5.0) indicates spironolactone effective in preventing hypokalemia

705

Laryngotracheitis

Croup

URTI
Hoarseness
BARKING COUGH (seal-like)
Stridor
Respiratory distress

Parainfluenza virus

706

Left sided heart failure symptoms

Pulmonary congestion

-Displaced PMI
-S3 sound
-Dyspnea
-Orthopnea (SOB when lying flat)
-PND (paroxysmal nocturnal dyspnea)
-Crackles

707

Right sided heart failure symptoms

Systemic venous congestion

-JVD
-Hepatomegaly
-Splenomegaly
-Ascites
-Edema

708

Mixing insulins

Intermediate-acting
Short-acting

1. clean tops of vials with alcohol swabs

2. Inject air into NPH without touching needle to solution

3. Remove and then inject air into regular

4. Invert regular vial and withdraw regular solution into syringe

5. Insert needle into NPH insulin vial and withdraw solution

*Remember: RN
Regular before NPH
(clear before cloudy)

709

Duloxetine
2 uses

SNRI
(serotonin-norepinephrine reuptake inhibitor)

1. Antidepressant

2. Pain-relieving effects
-Used to relieve chronic pain that interferes with normal sleep patterns in fibromyalgia
-Diabetic neuropathy

710

Mannitol

Osmitrol
Osmotic diuretic
-used to treat cerebral edema and acute glaucoma

Draws fluid from intravascular space to extravascular space.

If dose too high or accumulates (in kidney disease), fluid overload may cause:
pulmonary edema

Monitor:
serum osmolarity
I and O
serum electrolytes
kidney function

711

Macular degeneration
What is it?
S/S?

progressive incurable disease of eye where central portion of retina (macula) deteriorates with age.

Blurred, waves, or loss of vision in central field of vision.
-Peripheral vision remains intact

712

Abstinence Syndroms in neonate

-Most commonly seen with opioid use in mother

-Autonomic NS symptoms:
stuffy nose, sneezing, yawning, sweating, tachycardia, tachypnea
**Swaddle and keep nasal passages clear

-CNS symptoms:
irritability, high-pitched crying, restlessness, abnormal sleep pattern, hypertonic/hyperactive primitive reflexes
**Medication and protect skin

-GI symptoms:
poor feeding, vomiting, diarrhea
**small, frequent feedings

713

Tumor lysis syndrome

Potential compilation of chemo

Increased serum:
Potassium
Phosphorus
Uric Acid

Decreased serum:
Calcium

Electrolyte imbalances can lead to:
AKI
Dysrhythmias (vfib)

-IV fluids
-Allopurinol blocks nucleic acid catabolism to prevent hyperuricemia
***Also used for chronic gout and uric acid calculi

714

Topical Capsaicin
What is is?
How to use

OTC analgesic for minor pain (osteoarthritis, neuralgia)

Component of peppers that's HOT!!!

Instructions:
-Wait at least 30 min after massaging cream into hands before washing to ensure adequate absorption.
-Avoid contact with mucous membranes (nose, mouth, eyes) or skin not intact.
-No heat added! vasodilation, increased absorption, chemical burn
-Local irritation common in first week of use.
-Often used concurrently with Tylenol or NSAIDs for OA pain
-Use 3-4x/day for long periods

715

ARDS

Acute respiratory distress syndrome

Damage to areolar-capillary membrane, blood-gas barrier

-alveoli collapse and fluid leaks into alveolar space

-impairs gas exchange

716

Neurotic malignant syndrome

What is it?
Treatment?

Rare, life-threatening reaction d/t antipsychotics (usually typical like haloperidol, fluphenazine, but also atypical).

Characteristics:
-Fever
-Muscular rigidity
-AMS
-Autonomic dysfunction (sweating, htn, tachycardia)

Intervention:
DISCONTINUE ANTIPSYCHOTIC AND NOTIFY HCP.

717

28 week gestation assessment findings

-Lanugo (find downy hair) on back and shoulders
**begins disappearing around 36 wks gestation

-smooth, pink skin with visible veins

-areolae may be barely visible with no raised breast buds
**palpable raised (5-10mm) in newborns close to term

-fine wrinkles and few creases on sole of foot
**deep creases on entire sole of full-term

718

Prior to dialysis treatment, nurse should...

-assess fluid status (weight, BP, peripheral edema, lung/heart sounds)

-vascular access (arteriovenous fistula, arteriovenous grafts)

-vital signs

-last post-dialysis wt and current pre-dialysis weight to determine fluid removed (ultrafiltration)

AFTER connected to dialysis, IV heparin added to blood. NOT before, so no subcutaneous heparin

719

Incident/Occurrence Reports

Document events that pose unanticipated actual or potential risk to the health or safety of a client, visitor, or employee.

Form of QUALITY IMPROVEMENT. Not in health record.

Examples:
Assault and Injury-
physical, verbal, sexual assault, client falls with or without injury, staff and visitor falls with or without treatment

Treatment and intervention-
failure to obtain or intervene upon results of dx procedure, inadequate dx and monitoring, delay/omission of meds/therapies, hospital equipment failure

720

Minimal variability on fetal heart strip meaning

<=5 bpm
-Potential CNS depressants (opioid analgesics, narcotics, alcohol, illicit drugs)
-temporary fetal sleep
-prematurity
-fetal hypoxia

721

Febrile seizure management

1. Antipyretics
acetaminophen and ibuprofen (>6 months)

2. cool, damn compresses to forehead, increase air circulation, loose clothing

3. call 911 for sz >5 min

722

New onset dependent edema risks

Huge deal in the elderly!

Could be due to heart failure.

Need to assess for lung tackles and increased body weight

723

Neurological impairments from stroke.

Nurse teaching

-unilateral weakness/neglect on affected side
-impulsiveness
-aphasia

RN teaching:
**Improve visual perception--
-turn head to affected side
-scan environment
**Overcome unilateral weakness--
-dressing affected side first

Right sided CVA:
impulsive and unaware of deficits. May have outbursts.

724

Scabies

Sarcoptes scabiei mite

Person-to-person (nursing homes, day cares, prisons)

Intense itching, especially at night

-Pregnant female burrows (burrow track) into dead layer of skin, lays eggs and feces.
**30-60 day incubation period

-Treat all persons who have had contact with infested child during that time
->2 months can receive one-time treatment with scabicide cream (1% permethrin)
--apply everywhere below head
-Itching will continue for several weeks after proper treatment given

-scabies don't survive >2-3 days away from human skin.

Disinfect clothes, linens, stuffed animals by placing in plastic bag for minimum 3 days
OR
machine wash hot, dry on hottest
***fumigation of living area not needed

Hand hygiene:
soap and water, not gel

725

Constipation prevention

20-30 g of fiber daily

2-3 L fluids daily (avoid caffeine)

Exercise 3x/week

Healthy bowel regimen (avoid delaying defecation if urge felt)

Avoid laxatives and enemas unless prescribed. Overuse=dependency

726

Status epilepticus

Life threatening

Pt seizing >=5 min

Grunting and dazed appearance

RN PRIORITY:
1. STOP SZ if adequate airway/breathing

IV benzos (diazepam, lorazepam)
OR
rectal diazepam if IV unavailable

VP shunt at higher risk for sz

727

RN assisting with lumbar puncture

1. Verify informed consent
2. Gather the lumbar puncture tray and needed supplies
3. Explain the procedure to older child and adult
4. Have client empty the bladder
5. Place client in the appropriate position (eg, side-lying with knees drawn up and head flexed or sitting up and bent forward over a bedside table)
6. Assist the client in maintaining the proper position (hold the client if necessary)
7. Provide a distraction and reassure the client throughout the procedure
8. Label specimen containers as they are collected
9. Apply a bandage to the insertion site
10. Deliver specimens to the laboratory

728

Pharmacologic Nuclear Stress Test Instructions

-No eating, drinking, or smoking on day of test (NPO 4 hrs)
-avoid caffeine 24 hrs pretest
-avoid decaffeinated products 24 hrs pretest (trace amounts)
-No theophylline 24-48 hrs pretest
-Ask HCP about diabetes med adjustment for test in case of hypoglycemia
-Do not take following meds:
*nitrates (nitroglycerine or isosorbide)
*dipyridamole
*beta blockers

729

Ruptured ectopic pregnancy
Clinical Features

-Unilateral abdominal pain
-Hypotension (dizziness, tachycardia)
-Referred shoulder pain
***Life threatening hemorrhage


Symptoms of ectopic pregnancy:
-amenorrhea followed by vaginal spotting or bleeding
-palpable adnexal mass on pelvic exam

730

Clomiphene

Clomid
Infertility in women
-Stimulates ovulation

Orally for 5 days
Start 3-5 days into menses

Ovulation 5-9 days after medication complete

Frequent sexual intercourse every other day for 1 week.
-5 days after med complete is best chance for conception

Risks/Side Effects: multiple gestation
Mood swings, nausea, hot flashes, headaches

731

Common causes SIADH

CNS disruption
-stroke, infection, trauma, neurosurgery

Malignancies
-small cell lung carcinoma

Drugs
-desmopressin, carbamazepine

Pulmonary disorders
-pneumonia

732

Exophthalmos plan of care

Bulging eyes from Graves disease (hyperthyroid)

-artificial tears to moisten conjunctiva
-if eyelids don't close during sleep, sightly tape them shut
-dark glasses to prevent irritation
-smoking cessation
-raised HOB to drain fluid from area
-restrict salt intake
-intraocular muscle exercises to maintain flexibility
-regularly visit ophthalmologist

733

Hepatitis A transmission

Fecal-oral route

Wash hands after bowel movements and before eating most important


Needle sharing and unprotected sex discouraged.
Its >=1 yr should receive vaccine

734

Chlamydia

Most common STI

Most asymptomatic.
Sx:
-spotting after sex
-dysuria
-abnormal vag discharge

All sexually active women <25 and any client >=25 are served annually for chlamydia and gonorrhea.

Can lead to PID and infertility.

After treatment (1 dose azithromycin, 7 days doxycycline) abstain from sex for 7 days

735

Newborn abnormalities to report to HCP

Jaundice

Not voiding or passing meconium in first 24 hrs

Nasal flaring, chest wall retractions, and grating with respirations

736

Normal for newborns

Desquamation (peeling skin), especially post-term babies

Head circumference 12.5-14.5 in

737

Cardidopa-Levodopa

Treats bradykinesia (slow movement) in Parkinson's Disease

-may also help tremor and muscle rigidity
-do not stop suddenly!!! Akinetic crisis

738

Drugs
Increase memory in Alzheimers

Donepezil
Rivagtigmine

739

TSH

Thyroid stimulating hormone.

Released when not enough thyroid (T3/T4) is circulating

740

Iron deficiency anemia
Treatment

Foods:
leafy green veggies, red meats, poultry, dried fruit, fortified cereal)

Oral supplement:
-between meals
-give with citrus (Vit C)
-place med in back of mouth (can temporarily stain teeth)
-Don't give with milk (Ca reduced absorption)
-No more than 1 month supply on hand
-black or green tarry stools expected

741

Delirium S/S

-Acute mental status change that fluctuate
-Inattention with disorganized thinking
--hallucinations
-Altered LOC
-abrupt onset

(Unlike dementia: slow onset, normal attention)

Risk factors:
older age, prior cognitive impairment, infection, severe illness, comorbidities, dehydration, psychotropic med use, alcoholism, vision impairment, pain

742

How to stop epistaxis

Nose bleed

-Lean forward
-Apply direct, continuous pressure to nose for 5-10 minutes
-Pressure below nasal bone (nasal alae/Kiesselbach pleases)
-ice or cold cloth for vasoconstriction
-keep child quiet and calm

Avoid local trauma and maintain hydration of mucosa with saline nasal spray or humidifier

743

Folic Acid Dietary Sources

Excellent (100+mcg/0.5cup):
*fortified breakfast cereal
*fortified grain products (cereals, bread, pasta)
*Green leafy veggies
*cooked dried beans
*liver (consumed more for iron)

Good (40-100 mcg/0.5 cup):
-broccoli
-spinach
-green peas
-beets
-fortified spaghetti, pasta
-rice

Other (40-100mcg/serving):
tomato juice (3/4 cup)
1 orange
1 oz sunflower seeds
1 Tbsp PB
enriched bread (1 slice)

744

Antihistamines

diphenhydramine (Benadryl)
loratadine (Claritin)
promethazine (Phenegran)

Don't take 2 weeks before allergy test

745

Sulfa drugs

Sulfasalazine
Trimethoprim
Sulfamethoxazole

Treat bacterial infections or ulcerative colitis

Contraindications:
hypersensitivity
Pregnancy/breastfeeding

Assess for allergies to sulfa drugs and sulfonylurea meds (such as glyburide)

Side effects:
-Crystalluria potential adverse effect
-Drink at least 2-3 L water/day
-Photosensitivity
-Folic acid deficiency (megaloblastic anemia)
-Agranulocytosis (leukopenia)
-SJS

746

Kosher Dietary Laws

Orthodox Jews

NO:
pork
shellfish
fish without scales

When meat/poultry consumed, 3-6 hrs must pass before dairy consumed.

Neutral foods to eat anytime:
fresh fruits/veggies, grains, tea, and coffee

747

Biphosphonates

Used to treat osteoporosis and other bone loss diseases (Pagets disease)

Osteoblast=create
Osteoclast=destroy

*Encourage apoptosis of osteoclasts to slow rate of bone loss

Alendronate, risedronate, zoledronic

748

Abdominal assessment

Stand to RIGHT side

Inspect
Auscultate
Percuss
Palpate

749

dysthymia

persistent depressive disorder

750

Bell's Palsy

Peripheral, unilateral facial paralysis
*Inflamed cranial nere VII

-Inability to completely close eye on affected side
-Flat nasolabial fold
-Asymmetric smile/frown
-Altered tear production
-loss of taste on anterior 2/3 of tongue

Teaching:
*Apply patch or tape to affected eye at night
*Artificial tears during the day
*Chew on good side
*Maintain meticulous oral hygiene
*soft diet recommended

751

Hepatitis B
Transmission

Viral disease of liver characterized by inflammation, necrosis, and cirrhosis.

Blood
Semen
Vaginal secretions
(B: Body fluids)

unprotected sex
IV illicit drug use

Early sx:
malaise, nausea, vomit, bad pain.
Can lead to:
jaundice, wt loss, clay-colored stools, thrombocytopenia

752

1x pneumococcal vaccination

Does not prevent community-acquired pneumonia

>=65 should receive 2 pneumococcal vaccinations 1 yr apart.
(PCV13 and PPSV23)

Revaccination q5years for those immunocompromised, splenectomy, and >65

753

Pulmonary Embolism Assessment Findings

CP
Hypoxemia
Tachypnea
Pleuritic chest pain
Tachycardia
Anxiety/apprehension

Massive PE:
syncpope
hemodynamic instability

754

Pregnant with Genital Herpes

-Report to HCP ASAP
-Can be transmitted to infant in utero (congenital HSV), perinatally, or postnatally
-Neonatal HSV serious morbidity (permanent near sequelae) and mortality
-immediate antiviral therapy (ACYCLOVIE) initiated to treat active infection.
-C-section if active lesions

755

Live vaccines

Varicella
MMR
Influenza NASAL SPRAY

Wait in immunocompromised and post Kawasaki treatment (IV immunoglobulin)

756

Why diluting formula is no bueno

-Immature renal systems with low GFR can't excrete excess water.

-Potential water intoxication!
-Hyponatremia
---irritability, lethargy, and in severe cases, hypothermia an sz.

757

Peritonitis characterized by...

Fever
Abdominal rigidity
Guarding
Rebound tenderness

Potentially fatal

758

Tyramine foods

Cannot be eating with MAOI's

aged cheese
yogurt
cured meats
fermented foods
broad beans
beer
red wine
chocolate
avocados

759

Findings with pneumonia

Crackles
Dyspnea
Pleuritic CP
Bronchial breath sounds in perish lung fields
Unequal chest expansion
Dullness

760

Hyperresonance

Asthma attack
Emphysema
Pneumothorax

761

Amniotomy

About?
RN action

Artificial rupture of membranes

Augment or induce labor

Risk of umbilical cord prolapse
-can lead to fetal bradycardia d/t cord compression

RN action:
-note amniotic fluid color, amount, odor
*should be clear/colorless without foul odor
-Monitor temp q2hr (increased risk for infection)
-Assess FHR before and after procedure

762

Cystoscopy
What is is?
Complications include...

-scope inserted through urethra into bladder while in lithotomy position

Complications:
Urinary retention
Hemorrhage
Infection

Notify HCP if:
-bright red blood when urinating
-blood clots
-inability to urinate
-fever >100.4 and chills
-abdominal pain unrelieved by analgesia

Expected up to 48 hrs post cystoscopy:
-Pink-tinged urine
-frequency
-dysuria

Drink 4-6 glasses water/day, avoid alcohol and caffeine (24-48 hrs) because they irritate bladder

Mild analgesic and warm tub/sitz bath ok

763

What to consider when deciding appropriate method to transfer client safely

1. Can client bear weight?
2. Is client cooperative?

Yes and Yes?
transfer independently with standby assistance for safety.

764

Hiatal Hernia
RN actions

Part of stomach pushed through portion of diaphragm.
(Paraesophageal/Rolling hernia Medical Emergency)



-Elevate HOB 30 degrees (4-6 inch blocks under bed at home)
-Instruct client to avoid tobacco and caffeine
-Offer small, frequent, low fat meals
-Teach client to avoid lifting/straining
-weight loss

Do not wear girdle or tight clothing! Might increase intra-abdominal pressure

765

Rheumatoid arthritis

-Symmetrical pain and swelling the tonically affects small joints of hands and feet

-morning joint stiffness that lasts from 60 minutes to several hours

-elevated ESR and rheumatoid factor levels

766

Osteoarthritis

Asymmetrical pain in the weight bearing joints

-Crepitus, especially over knee joints
-morning stiffness subsides within 30 min
-Atrophy of muscles that support joint
-Decreased ROM

767

Menopause teaching
(post age 51)

At risk for osteoporosis and heart disease.

-Bisphosphonates (alendronate, risedronate, ibadronate) decrease bone resorption to slow decreasing bone density
*take on empty stomach with full glass of water
*sit upright for 30 minutes

-calcium and Vit D needed (food and supplements)

-HRT can improve bone mass but can lead to thrombotic complication and some cancers.
*only used for disabling hot flashes
*watch out for unilateral leg swelling

-postmenopausal bleeding or abnormal premenopausal bleeding most common sx of endometrial cancer. Requires follow up!

768

Foods for pregos to avoid

due to bacteria (Listeria, toxoplasmosis)contamination

-unpasteurized milk products
-unwashed fruits/veggies
-deli meat
-hot dogs (unless headed until steaming hot)
-raw fish/meat

-fish high in mercury
(shark, swordfish, mackerel, tilefish)

769

Small bowel follow-through

X-rays of small intestine to examine anatomy and function.

Barium ingested, x-ra taken every 15-60 minutes to visualize barium as it passes through.

-Fast 8 hours prior
-Test 60-120 minutes
-Drink a lot of fluids post-procedure
-Chalky stools 24-72 hours post

770

Interior vena cava filter

What is it?
Teaching

Metallic filter that traps blood clots from LE and prevents them from becoming PE's.

Discharge teaching:
-Regular physical exercise
-Alert HCP's before body scans (metal object)
-Avoid crossing legs to promote venous return
-Leg pain, numbness, or swelling needs to be reported
-Report s/s of PE (CP, SOB)

771

-floxacin
Risk

Ciprofloxacin, levofloxacin, moxifloxacin, nofloxacin, ofloxacin

TENDINITIS AND TENDON RUPTURE!
Most commonly Achilles tendon.

Black box warning about the risk.

First sign? tendon pain or swelling
-stop med
-abstain from moving affected area
-contact HCP

772

When speaking to a client with hearing impairment

room lights on

directly face the client

speak at a normal volume toward the least-affected ear

ensure that any hearing aids are functional and in place

Hearing impairment signs may be posted to promote safety.

773

Catatonia

Might be with schizophrenia

2 of the following for dx of catatonia:
-immobility
-remaining mute
-bizarre postures
-extreme negativism (resists instructions)
-waxy flexibility (limbs stay in same spot someone else moved for them)
-staring
-stereotyped movements, prominent mannerisms, grimacing


Unable to meet basic needs.
At risk for dehydration and malnutrition

774

Inactivated vaccines

OK for pregnancy

Tdap (tetanus, diphtheria, pertussis)
27th and 36th week of gestation

Inactivated influenza vaccine
--NOT NASAL SPRAY
--any trimester (Oct-Mar)

775

Who not to treat during disaster (black tag worthy)

-Pulselessness
-Apnea
-Severe neuro trama (ex. fixed dilated pupils)
-Full-thickness burns >60% BSA

776

Pavlik harness

-For developmental dysplasia of the hip (DDH)

-hips slightly flexed and abducted

-worn 3-5 months
-straps assessed q1-2weeks by HCP
-parents should not alter strap placement
-assess skin 2-3x/day
-shirt and knee socks under harness
-diapers underneath straps
-leave on at all times
-lightly massage under straps daily to promote circulation

777

Stages of Labor

1: Latent (0-5cm)
Active (6-10cm)

2: 10cm-birth

3: Birth-expulsion of placenta

4: 1-4 hrs post birth, maternal physiologic readjustment

778

Labor meds
How far along before meds?

-systemic analgesia given during active phase (at least 4-5cm)
-4 cm in multipara

-contractions should be well established
(~3-4 min)

-butorphanol
-nalbuphine
*bolus IV push over peak of 2 contractions to decrease amount going to fetus

-ceiling effect, only 3 doses given because more won't help

-don't use in opioid-dependent client (precipitate withdrawal)

779

Thyroid storm
What is is?
S/S?

Hyperthyroidism
Excessive secretion of TH

Life-threatening!

-fever
-tachycardia
-cardiac dysrhythmias (eg, atrial fibrillation)
-nausea
-vomiting
-diarrhea
-altered mental status.

Client management:
-reduce fever
-hydrate
-prevent cardiac compromise (HF)

780

Acceptable pulse ox for normal, healthy nonsmoking adult

95-100%

90% is LOW and indicates inadequate depth or rate

781

Radioactive iodine uptake test

-Scan done at 2, 6, 24 hrs to assess absorbing iodine
(narrow dx to Graves)

RN considerations:
-notify HCP if other iodine contrast used
-Thyroid meds held for 5-7 days prior
-prego test for premenopausal women

Pt education:
-NPO 4 hrs pre
-Eat 1-2 hrs post swallowing iodine
-Remove dentures and jewelry/metal around neck
-Increase fluids post-test to clear iodine
-You'll be awake! No discomfort
-Do not breastfeed right afterwards

782

Wound irrigation

-Analgesis 30-60 min before
-Gown, mask w/ face shield, sterile gloves
-30-60mL sterile irrigation syringe
-18-19 gauge needle or angiocatheter
-hold 1 inch above area
-Continuous pressure until drainage clear
-dry surrounding wound area to prevent skin breakdown
-clean from least to most contaminated area (prevents recontamination)

783

Signs of imminent birth

Precipitous birth is <3 hrs of labor

involuntary pushing/breaking down with contractions

grunting

report of sensations of having BM

*If pt arrives in second-stage of labor (i.e.,pushing) nurse needs to apply gloves and observe perineum for crowning

784

Interventions to prevent abdominal wound dihiscence

-stool softeners
-antiemetics (prevent nausea/vomit)
-abdominal binder
-tight glycemic control
-splint abdomen when coughing/moving

785

Nursing interventions for clients with acute viral hepatitis

-alternate rest/activity
-avoid hepatotoxins (alcohol, acetaminophen)
-use caution with meds metabolized in liver

-low fat (impaired bile production), small, frequent meals to decrease nausea
-larger breakfast (anorexia lowest in am)
-oral care
-avoid extremes in food temp
-promote water consumption

-do not share razors or toothbrushes
-condoms for sex

786

Ineffective coping in labor

-crying, sweating, hyperventilating
-tenseness; tremulous voice
-thrashing, wincing, writhing
-inability to focus/concentrate
-clawing, biting, screaming
-panicked activity with contractions

787

Highest risk for MRSA

-older adults
-suppressed immunity (chronic illness)
-long hx of antibiotic use
-invasive tubes or lines (hemodialysis, vent pts)

***pts in ICU***

788

High retention of CO2 level in COPD
(hypercapnia respiratory failure)
RN intervention

Bilevel positive airway pressure (BIPAP) machine

-(+) pressure and expel CO2 from lungs

789

Blood pressure after ischemic stroke

Usually elevated as compensatory mechanism
"Permissive HTN"

Usually autocorrects within 24-48 hrs

Only requires treatment for extreme HTN
>220 OR >120

790

Major complication with
joint replacement surgery

Infection!!!

Especially obese people
---also at risk for post-op pneumonia (impaired pulmonary function, sleep apnea, hypoventilation)

791

Normal infant
-respiratory rate
-temperature
-blood glucose

30-60/min

97.7-99.7

40-60 (within first 24 hrs)

792

Myasthenia crisis

Exacerbation of myasthenia graves (AID)

Caused by:
-infection
-undermedication (pyridostigmine)
-stress

Characterized by:
-oropharyngeal and respiratory muscle weakness
-respiratory failure

***IMMEDIATE INTERVENTION***

793

Trigeminal neuralgia

Pain/Triggers
Drug of choice/Side-effects
Client self-care

Sudden, sharp (usually unilateral) pain along mandible or maxillary zone.

Drug:
carbamazepine
-seizure med
-highly effective for neuropathic pain
-associated with agranulocytosis (leukopenia) and infection risk
***Report any fever/sore throat***

Pt care:
-oral care: small, soft-bristled toothbrush or warm mouth wash
-lukewarm water
-avoid food temp extremes
-room moderate temperature
-avoid rubbing/favial massage (cotton pads to wash face if needed)
-soft diet, high calorie content
-chew on unaffected side of mouth

794

pneumonectomy post op patient position

Client should be positioned on surgical side

We want maximum expansion of the REMAINING LUNG!

795

Percutaneous Nephrolithotripsy

What is it?
Complication?

-Nephroscope breaks/remove large kidney stones
-Leave temporary tube to prevent obstruction by stone fragments
-Tube potency critical!

-No drainage???
-GENTLE IRRIGATION!
-sterile NS, aseptic technique

796

Rhabdomyolysis:
Cause
Complication
Immediate Treatment

Muscle fibers released into blood b/t of muscle injury
-exercise
-heat stroke
-physical trauma

Acute renal failure
-elevated myoglobin overwhelm kidneys

-Rapid IV fluid resuscitation to flush damaging myoglobin

S/S of rhabdo:
-dark, sometimes bloody urine
-oliguria
-fatigue

797

Clang associations

Schizophrenia

Rhyming words in meaningless, illogical manner

"the pike likes to hike and Mike fed the bike near the tyke"

798

Perseveration

Schizophrenia

Repeating same words/phrases in response to different questions

799

Pursed-lip breathing technique

Inhale for 2 seconds through nose, keeping mouth closed

Exhale for 4 second through pursed lips

COPD pts

800

Cranial nerve IX

Glossopharyngeal

gag reflex
ability to swallow
phonation
taste

SWALLOW PRECAUTIONS

Possibly damaged during laryngectomy
If so, client needs to learn supraglottic swallow

801

Cranial Nerve VIII

Vestibulocochlear

Hearing and equilibrium

Impairment: loss of hearing, dizziness, vertigo, fall risk

802

Bishop Score

Cervical favorability and readiness for induction of labor

10=highest score
>8 in nulliparous women successful induction and subsequent vaginal birth

Consistency (0-2): firm, medium, soft

Position (0-2): Posterior, mid-position, anterior

Dilation: 0, 1-2, 3-4, >5 (0-3)

Effacement: 0-30#, 40-50%, 60-70%, >80% (0-3)

Station: -3; -2; -1,0; +1, +2 (0-3)

803

Most accurate indicator of fluid loss or gain

daily weight

(in acutely ill clients)

804

MMR Vaccine

12-15 months

Can be given earlier within 72 hours of initial measles exposure.

If administered within 6 days, post-exposure prophylaxis

IF they receive it early, they will need to be revaccinated 12-15 months and again 4-6 yrs

805

Hypothyroidism symptoms

Bradycardia

Wt gain, constipation

Fatigue, muscle aches, joint pains

Lethargy, apathy, forgetfulness, depression

No period, always menstruating; infertility, decreased libido

Cold intolerance, dry and thick skin, brittle nails and hair, hair loss, facial and generalized edema

Anemia (pallor)

806

Sequence of BLS for unconscious, pulseless pt

1. Verify response (are you ok?, shake awake)

2. Call for help-emergency response team activated for all unresponsive clients

3. check for breathing/pulse or 10 seconds

4. begin chest compressions

5. notify the HCP

807

Histrionic personality disorder

Center of attention

Exaggerate emotional expression

Little tolerance for frustration

Attention-seeking

Overly-friently/seductive, attempts to keep others engaged

Demands immediate gratification

808

Antisocial personality disorder

Disregard for and violate the rights of others

Manipulate others for personal gain and lack empathy

809

Metoclopramide
Use?
Normal side effects?
Emergency side effects?

Use:
delayed gastric emptying, GERD, antiemetic, nausea, vomit, GASTROPARESIS

Promotes GI motility and stomach emptying.

NORMAL side effects:
sedation, fatigue, resteless, headache, sleepy, dry mouth, constipation, diarrhea

EMERGENCY Side effects?
Similar to antipsychotic drugs, extrapyramidal adverse effects...
-TARDIVE DYSKINESIA (uncontrollable movements, sucking/smacking lips)
-protruding/twisting tongue
-lip smacking
-chewing movement
-frowning or blinking of eyes
-twisting fingers
-twistied or rotated neck (torticollis)

810

Tumor necrosis factor inhibitor drugs:
-Names
-Uses
-What to check before admin
-Complications

Adalimumab
Etanercept
Infliximab

Also used for rheumatoid arthritis

Need baseline Tuberculin Skin Test (TST) beforehand. Latent TB must be treated before imitation of TNF drugs

Complications:
Cause immunosuppression and infection
Elevated WBC is NO BUENO!

811

What does liver do/produce

Clotting factors (with Vit K)

Breaks down old or damaged blood cells

Bile production/excretion

Synthesis of albumin

Excretion of bilirubin, cholesterol, hormones, and drugs

812

Patient positioning with pneumonia

GOOD LUNG DOWN

813

Liver failure/dysfunction lab abnormalities

*Low serum albumin (edema)

*High ammonia (hepatic encephalopathy, asterixis, coma, confusion)

*Elevated INR/long PT (bruising, bleeding)

*Increased bilirubin (jaundice, itching, scleral icterus)

*Low platelets (petechiae, spontaneous bleeding)

814

Prolapsed umbilical cord positions

Hands and knees (knee-chest position)

Trendelenburg

815

Multiple sclerosis
What is it?
S/S?
Pt interventions

Progressive, demyelinating disease of CNS.

S/S:
muscle weakness, spasticity, incoordination, loss of balance, fatigue
Risk for fall/injury

Interventions:
-Stretch, strengthen, ROM
-Walk with feet apart (increase base support), improves steadiness and gait
-Assistive devices (cane, walker) usually required as progression occurs

-wheelchairs only i gait training unsuccessful.
Independence as long as possible.

816

Phentolamine

What does it do?
What does it treat?

Antihypertensive drug
Vasodilator

BP
Pheochromocytoma

817

Gastroduodenostomy
What is it?
Client teaching
RN intervention

AKA: Billroth I

Removes distal 2/3 of stomach

Teaching:
-frequent, low carb, moderate protein, moderate fat meals
-no drinking with meals (dumping syndrome)
-turn, cough, deep breath while splinting

RN:
-elevate HOB
-do NOT manipulate or flush post op NG tube
-might cause hemorrhage or gastric perforation

818

African american disease risks

HTN
Cervical cancer
Ischemic stroke (RF: htn,DM, sickle cell)

819

Broca Aphasia

Expressive aphasia

frontal lobe damage

Speech sparse and nonfluent

Comprehension relatively preserved

Client frustrated while attempting to speak

Limited to short phrases that require effort. Usually omit smaller words ("and", "is", "the")

820

Wernicke Aphasia

Receptive aphasia

temporal lobe damage

Inability to comprehend the spoken and/or written word

Long meaningless speech pattern

821

Orthodox Jew postmortem care

1. Sheet over face (dead disrespected if effects of death seen on face)

2. Autopsies not permitted
UNLESS
-required by law
-pt provided consent before death
-hereditary disease and it would help save others

Believe body belongs to Go and that a complete burial is required to enter heaven.

If autopsy required, all organs and fluids returned to it before burial.

3. family member always with them

822

Arterial angiogram

Arteriography

Catheter inserted and dye injected to make blood vessels visible by x-ray.
-assesses for occlusions (embolism), injuries, aneurysms, abnormalties

Frequent neuromuscular checks of affected extremity (temp, distal pulses, color, cap refill, sensation, movement).

823

Cranial Nerve V

Trigeminal

Chewing
SWALLOW PRECAUTIONS (if damaged)

824

Swallowing affected by which cranial nerves?

IX (glossopharyngeal)

X (vagus)

825

Indications of contaminated blood

-Green, black, white, or dusky discoloration
-accumulations of air
-evidence of clotting or presence of inclusions
-malodor

826

Cyclosporine

Immunosuppressant

RA
Psoriasis
Prevent transplant rejection

RISK FOR INFECTION

Takes 1-2 months for full effect of therapy

Secondary malignancies (skin cancer, lymphoma) increased in these pts

-increases hair growth
-gingival hyperplasia
-hypertension
-nephrotoxicity
-avoid grapefruit juice

827

peristomal care

-cleanse skin with ild soap and water

-ensure ostomy appliance fits well

-trim appliance opening 1/8 inch larger than stoma so it "hugs" stoma without toughing stoma tissue

828

Ileostomy

-Formed from small intestine to bypass colon
-incontinence of liquid stools

-change appliance every 5-10 days

-empty at 1/3 full

-encouraged to increase fluid intake (dehydration, hypokalemia, and dehydration risk)

829

Verapamil

Calcium channel blocker

Sometimes used for the prevention of migraines.

830

Septic arthritis

infectious arthritis

-Fever
-Joint swelling with effusion
-Limited range of motion
-Moderate to severe pain

Possible irreversible joint damage

NOT numbness below in the extremity (not a nerve problem)

831

Decrease risk of pressure injuries in sedated infants

-HOB 30 degrees
-Moisture barrier to any vulnerable areas
-Reposition pulse ox q4h

NO baby powder
NO donut pillows

832

Alateen
vs.
Al-anon
vs.
ACOA

Alateen:
support to adolescent children of alcoholics

Al-anon:
help for spouses, significant others, family and friends to share personal experiences and coping strategies

ACOA:
adult children of alcoholics
For adults who grew up in dysfunctional homes d/t alcoholism

833

Rabies:
Risks

Post-exposure prophylaxis

Dog/Bat
Affects CNS
Viral encephalitis
Death r/t cardiovascular and respiratory collapse

1. Immediate wound care (scrub with povidone-iodine or soap and water)

2. admin tetanus toxoid vaccine (if not current)

3. Admin human rabies immunoglobulin INTO proximal wound area.
Passive immunity.

4. Admin human rabies vaccine IM. Active immunity.
Shot on day of exposure and 3, 7, 14 days post-exposure.

834

Superior vena cava syndrome

Tumor obstructing SVC

Facial edema
Facial plethora (fullness, red complexion)

Venous distension distal to obstruction

835

Decorticate posturing

Flexion posturing

-Arms rigidly flexed at elbow
-Hands raised to chest
-Legs extended

Suggests worsening cerebral impairment (increased ICP).
May be reversible with proper interventions

836

hemiparesis
hemiplegia

Paralysis of one side of body

837

Removing PPE

Gloves
Goggles/face shield
Gown
Mask/Respirator

Remove in alphabetical order

838

Compression of oculomotor nerve III

Fixed dilated pupils

Indicates increased ICP

839

Otorrhea

CSF leaking from ear
-possible skull fx

NOT directly related to increased ICP

840

Names of random anticoagulants

Not heparin, LMWH, or warfarin

apixaban
rivaroxaban
edoxaban

841

Meds/electrolyte imbalances that prolong QT and may precipitated torsades

Antiarrhythmics:
sotalol
amiodarone (fib, SVT, arrest, etc.)
ibutilide
dofetilide

Macrolide antibiotics:
-mycins

Electrolyte abnormalities:
hypomagnesemia
hypokalemia

842

Fetal tachycardia:
Causes
RN intervention

Causes:
-fetal hypoxia
-acidosis
-infection
-maternal fever
-maternal dehydration
-maternal hypotension
-drug side effects
(terbutaline, bronchodilators, decongestants)

RN action:
-take maternal temp
-take maternal BP
-review med administration record
-increase IV fluid rate if hypotension

843

Culture sensitivity testing for infants

Urine needed
Sterile technique

-Sterile cath for infants and toddlers who are not toiled trained

844

Varicose Veins
Treatment
Potential complications

TREATMENT
-weight loss
-3 E's:
Elevation
Exercise
Elastic compression hose

COMPLICATIONS
*Chronic Venous Insufficiency*
-Warm, thick, indurated skin
-bronze/brown pigmentation of skin
-edema
-ulcer

845

Monitor tube feeding for complications/intolerance

*BOWEL MOVEMENTS:
Diarrhea
-too concentrated/hyperosmolar or too rapid

FLUID STATUS
-rapid weight gain, periph edema
-Too dilute or excess water flushes

DELAYED GASTRIC EMPTYING
-Nausea/Vomiting
-high gastric residuals

846

How to position pt if unable to hear heart sounds

Aortic/Pulmonic areas:
Sit up and Lean forward

Mitral area:
Lie down on left side

847

Dissociative identity disorder
What is it?
Treatment goal?
RN intervention?

2 or more identities, response to abuse/trauma.
-might not be aware
-gaps in memory/"lost time"

GOAL:
to integrate ID's into 1 personality safely

RN:
-trust with each id
-encourage journaling and dissociation triggers
-listen for expressions of self-harm
-teach grounding techniques to hinder dissociation
-Allow recall of memory at own pace

DO NOT force client to recall memories.

848

OCD
Initial nursing care

-help pt identify anxiety triggers
-positive feedback when non ritualistic
-nonjudgmental and empathetic
-reflective communication
-cognitive-behavioral therapy (eg, thought stopping)

849

Hyper/Hypo
Calcium

Calcium acts as diuretic and sedative

Hyper: constipation and polyuria

Hypo: neuromuscular excitability
-tremors, hyperactive reflexes, sz

850

Hyper/Hypo
Potassium

Hyper: peaked T-waves, muscle twitches, cramps, paresthesis, decreased bb, diarrhea

Hypo: weakness, fatigue, confusion, irritable, thready pulse, low intestinal motility

851

Benztropine
Use

Anticholinergic med for some EXTRAPYRAMIDAL SX , which are associated with some antipsychotic meds.

Pseudoparkinsonism: symptoms resembling PD (mask like face, shuffling gait, rigidity, rest tremor, bradykinesia)

Dystonia:
Abnormal muscle movements of face, neck, trunk by sustained muscular contractions

852

Pharyngitis
cause
Interventions

Group A B-hemolytic Streptococcus bacterial throat infection

-Could cause renal or cardiac complications if not treated

Interventions:
-Antibiotics!!!
*kid can return to school 24 hrs post if afebrile
*throw away toothbrush 24 hrs post
-test siblings age <3
-complete all antibiotics

853

Active TB combined therapy

Drugs

Length of therapy

Isoniazid
-hepatotoxicy
-peripheral neuropathy

Rifampin
-hepatotoxicity
-red urine, sweat, tears (no contact lenses)
-Decrease oral contraceptive effectiveness
-increased metabolism of hypoglycemia and warfarin

Ethambutol
-occular toxicity (frequent eye exams)

Pyrazinamide

LOT:
6-9 months

854

placenta accreta

Most morbid cause of retained placenta

Adheres to myometrium

Attempted separation=life-threatining hemorrhage

855

Barotrauma

Potential complication of high levels of PEEP (10-20 cm H2O)

-abrupt pressure change

-RUPTURED ALVEOLI!
*pneumothorax and/or subcutaneous emphysema

856

Reduce risk of aspiration in pt with tracheostomy

-cuff makes it hard to swallow/talk

-cuff deflated when client improving

-client sit upright with chin flexed towards chest
-monitor for wet/garbled-sounding voice
-monitor for fever

857

Furosemide

Lassie

K-depleting loop diuretic

858

Shingles

Herpes zoster

Open lesions- AIR AND CONTACT PRECAUTIONS

Disseminated shingles:
CONTACT
AIRBORNE
NEGATIVE-AIRFLOW ROOM

Localized shingles:
standard precautions for clients with intact immune system and covered/contained lesions

859

Cranial Nerve XI

Spinal accessory

Shoulder muscles

860

Hyperemesis gravidarum

Persistent nausea an vomiting

Dehydration
Concentrated urine
Hypokalemia
Hyponatremia
Ketonuria (body breaking down fat for energy)

861

Emergency contraception

Within 5 days

Efficacy reduced after 3 days

862

CF diet

High calorie
High protein
High fat

863

Bronchial breath sounds

normally heard over trachea
-harsh, high-pitched

If heard over lung periphery, indicates pneumonia
(consolidation)

864

Borborygmi

Loud, gurgling bowel sounds.

Potentially gastroenteritis, diarrhea, and early phase of mechanical obstruction

865

Normal muscle strength

5=NORMAL! Active motion against full resistance
4=active motion against some resistance
3=active motion against gravity
2=only able to move laterally, not against gravity
1=slight flicker of contraction
0=paralysis

866

Transverse myelitis

spinal cord inflammation

S/S
paralysis
urinary retention
bowel incontinence

867

Midazolam
Use
Antidote

Conscious sedation for endoscopic procedures

Antidote:
Flumazenil

868

Acute angle-closure glaucoma
VS
Open-angle glaucoma

Acute-angle:
Medical emergency
Increased IC pressure
Permanent blindness
S/S:
-severe pain
-reduced CENTRAL -vision
-blurred vision
-ocular redness
-halos around lights


Open:
gradual loss of peripheral vision
difficulty adjusting to light
Develops slowly, not emergent

Eye redness from increased pressure

869

Asthma its cannot use which meds?

Beta blockers

NSAIDS (ibuprofen, aspirin)

870

Guaifenesin

aka: Mucinex

expectorant to mobilize mucus

871

Loratadine

aka: Claritin

antihistamine

872

Clear Liquids
vs.
Full liquids
vs.
Soft Diet

Clear:
clear broth, jello, popsicles, clear fruit juice (apple, grape), carbonated beverages (sprite, ginger ale), coffee, tea

Full:
strained/blended cream soups, custards, puddings, cooked cereals (oatmeal, grits), all fruit juices, ice cream, frozen yogurt, sherbet, milkshakes

Soft:
soups, flaky fish, PB, scrambled eggs, mashed potatoes

873

Bariatric surgery post-op

-NG tubes contraindicated (don't mess with surgery site!)

***Clear liquid diet for 48-72 hrs to promote healing
*Full liquids after that.
*Low-carb (sugar-free) liquids to decrease dumping syndrome

-Low fowler's position for meal times to slow gastric emptying

-Morphine and PCA used for pain management

874

Phenylketonuria
What is it?
treatment?

-Genetic
-Lack enzyme phenylalanine, used to convert then to tyrosine.
-Unconverted then accumulates, leads to irreversible near damage

TREATMENT:
Low-phenalalinine diet (safe serum level 2-6 mg/dL for clients <12)
-Lifetime dietary restriction
-special formulas ended
-Eliminate high-phen foods (meat, eggs, milk)
-encourage consumption of natural foods w/ low phen (fruits/veggies)

875

Fluticasone/salmeterol

fluticasone=corticosteroid
salmeterol=bronchodilator

Long-term control of asthma, not rescue inhaler

-after inhalation, rinse mouth with water without swallowing
-avoid smoking
-receive normal vaccines

876

Rescue asthma meds

albuterol
ipratoprium

877

Azathioprine

immunosuppressant

can cause bone marrow depression

increased risk for infection

Leukopenia severe adverse effect

878

Rheumatoid Arthritis
What is it?

-Chronic, relapsing autoimmune disorder
-Inflammation of synovial joints
-fibrosis/stiffening of synovial membranes
-contracture of ligaments
-joint remodeling
=weakness/deformity
*joint deformity can be prevented with drugs and joint protection
-ROM exercises to prevent loss of function and prevent contracture

PREVENT DISEASE PROGRESSION:
-joint protection (body aligners/immobilizers at to keep joints straight rest)
-Medications
***methotrexate (anti rheumatic drug)
***take as prescribed regardless of symptoms
-ROM exercises, stay active

879

OA vs RA

OA:
-degenerative cartilage loss
-Morning stiffness less than 30 min
-asymmetrical
-heberden's node
-localized joints, 1 or a few joints

RA:
-autoimmune
-inflamed synovium
-(late)extra-articular (joint) involvement... deformities
-symmetrical
-Morning stiffness more than 30 min

880

Nystatin

Treats oral candidiasis (thrush)

Available in powders, suspensions, creams, ointments, lozenges

Oral suspension used for oral candidiasis.
*Swish in mouth for several minutes
*SWALLOW

-ointments for skin
-lozenges need to be dissolved in mouth

881

Myasthenia Gravis

What is is?
S/S?
Treatment?

Autoimmune disease
-Decrease acetylcholine receptors

S/S:
**EYES, SPEAKING, SWALLOWING, BREATHING***
-ptosis/diplopia
-bulbar signs (difficulty speaking/wallowing)
-difficulty breathing
*stronger in the morning, weaker with the day's activity
-skeletal muscle, NOT CNS (so bladder/bowel control ok)

Treatment:
-anticholinesterase BEFORE MEALS (AC)
*pyridostigmine*
-Annual flu vaccine
-Pneumonia vaccine
-Semi-solid foods (over solid foods)

882

Cholinergic actions vs Anticholinergic actions

Cholinergic:
-Pupil constriction (mitosis)
-Decreases HR
-Causes urination

Anticholinergic:
-Pupil dilation (mydriasis)
-Increases HR
-Causes urinary retention

883

Nitrazine test
What for?
Results?

Determines if membranes ruptured (labor)

Negative: yellow, olive-yellow, olive green (pH5-6)
*membranes intact*

Positive: blue-green, blue-gray, deep blue
(pH6.5-7.5)
*membranes ruptured*

FALSE POSITIVES:
Semen
Blood

884

Thrombolytic agents
Use
Contraindications

-PLASE
anteplase, tenecteplase, reteplase

Resolve acute thrombotic events
(ischemic stroke, MI, massive PE)

Contraindication:
-uncontrolled hen (>180/110)
-active bleeding
-recent trauma
-aneurysm
-hx of hemorrhagic stroke

885

Penicillin derivatives and cephalosporins safe for pregos?

MOST, YES!

ampicillin
amoxicillin
cqphalexin
ceftriaxone

886

Fundal height based on weeks pregnant

12: just above symphysis pubis
20-22: reaches umbilicus
36: approaches xiphoid process
38-40: engagement occurs, starts to drop

At 20 weeks, fundal height measured in centimeters
Pubic bone=0cm
Measuring tape over belly towards breasts

887

Chest physiotherapy

Cystic fibrosis

AFTER bronchodilators and neb

BEFORE meals

888

Newborn respirations

Rate:30-60

Periodic pauses lasting <20 seconds

889

Myopia

nearsightedness
(can't see objects far away)

-headaches
-dizziness
-low school performance
-rubbing ees
-frequent blinking/squinting

Biconcave lenses or laser sx

890

Stabismus

What Jamie Eason's kid has!
One eye drifts
*malalignment*
Kids will close one eye when viewing objects

891

Veracity

Telling the truth

892

Fidelity

Loyalty
Keeping promises
Fulfilling commitments (accountability)

893

Justice

equal treatment for all

894

Drugs most commonly associated with orthostatic hypotension

1. antihypertensives (Beta blockers, alpha blockers-terazosin)
2. antipsychotics and antidepressants (olanzapine, risperidone, SSRI's)
3. diuretics
4. vasodilators (nitro's hydrazine)
5. narcotics

895

Retinal detachment symptoms

Painless loss of vision "like a curtain" coming across field of vision

Light flashes

Floaters

Gnat/hairnet appearance in vision field

EMERGENT EVALUATION!!!

Untreated-blindness

896

Age for heimlich maneuver

Over 1

Fore tin body aspiration

Upward abdominal thrusts

897

Gold standard to assess early ventilation failure

Serial Bedside Forced Vital Capacity
(spirometry)

898

Eosilophils

1-2%
Elevated in allergies and asthma

899

Lymphocytes

Elevated with viral and hematologic malignancies

900

Neutrophils

55-70%
Elevated in infection

901

Stages of Change Model

Pre contemplation: "no problem"

Contemplation: understand change needed, but is it worth it?

Preparation: established goals

Action: active steps towards new behavior

Maintenance: Prevent relapse

Termination: change achieved

902

American Diabetic Association Meal Planning

High fiber (whole grains, legumes, fruits, veggies, low-fat dairy)
Low glycemic index
Monounsaturated fats (no burgers)
Reduce sodium
Limit sucrose
Limit alcohol

903

Rapid response team criteria

Acute change in the following:
-Hr <40 or >130
-SBP <90
-Resp rate <8 or >28
-O2 sat <90%
-Urine output <50/4hrs
-Level of consciousness

904

Coup-countrecoup

Body in motion suddenly stops (ex. car slamming into wall)

Frontal lobe: executive function, memory, SPEECH (Broca are), and voluntary movement

Occipital lobe: vision

905

Phenazopyridine

Urinary analgesic
For UTI's

Will turn urine (and other bodily fluids) bright red-orange

906

Pyrosis
What is it?
Lifestyle changes to treat

Heartburn
Common in pregnancy
Esophageal sphincter relaxation

-Elevate HOB
-Sit upright after meals
-less fluid while eating
-Small, frequent meals
-Avoid tight clothes
-Eliminate dietary triggers (fried/fatty food, caffeine, citrus, chocolate, spicy foods, tomatoes, carbonated drinks, peppermint)

Dairy isn't typically a problem :)

907

Presbyopia

Farsightedness

Loss of elasticity of lends

Old age

908

Vancomycin
Used for?
Lab checks?
Risks?

MRSA, C.Diff

BUN (12-20)
Creatinine (1-1.5)

Serum trough level monitored before 4th dose.
15-20 mg/L ideal1

NEPHROTOXICITY!

909

Maintain gastric suction using Salem Sump Tube

NG Tube

-Semi-fowlers position
-Mouth care q4h
-Turn off suction during auscultation
-Inspect drainage system for patency
-Keep air vent (blue pigtail) open and above level of clients stomach

NO RESIDUAL! It's on suction!

910

Mononucleosis
What is it?
Sx?
Treatment?

Epstein-Barr VIRUS

Fatigue, sore throat, fever, swollen lymph nodes, splenomegaly, hepatomegaly

NO ANTIBIOTICS! IT'S A VIRUS!!!

Treatment:
manage symptoms :(
hydration, rest, pain control, reduce fever
Saline gargles or anesthetic troches (lozenges)

Avoid contact sports b/c of splenomegaly.

911

Sulfonylurea medications

Names
Use
Adverse effects

glyburide
glipizide
glimepiride

Type 2 diabetes
Increase insulin release from beta cells in pancreas

Side effects:
Hypoglycemia
Weight Gain

Extra info:
Avoid alcohol d/t risk of severe hypoglycemia

Glyburide: sunburn easily

912

Liver Biopsy

-Check its PT/INR and PTT
-Type and crossmatch blood type
*bleeding risk!
Lie supine
Right arm under head
Exhale and hold during insertion
Needle b/w 6th-9th ribs
Lie on right side 2-4 hrs
Bed rest 12-14 hrs

913

Normal vs Abnormal Lymph Node findings

***NORMAL***
Usually non palpable

Small (0.5-1cm)
Mobile
Firm
Contender
ALL NORMAL!

Could be from recent trauma, inflammation

***ABNORMAL***
tender, enlarged
hard, fixed- potential malignancy

914

Sucralfate

Protective layer in GI mucosa!

Empty stomach
May bind with other meds
(take 1-2 hrs away from sucralfate)
Potential constipation

915

Sarin

Biological weapon
Nerve Agent

Excess acetylcholine

Mitosis, rhinorrhea, copious secretions, SOB, flaccid paralysis

Treat:
suction
support ventilation

916

Botulism

Neurologic symptoms

Symmetrical descending paralysis
Cranial nerve palsies (ptosis diplopia, dysphagia, dysphonia)

917

Pessary

Vaginal device to support prolapsed bladder

-No surgery
-Fitted for proper size
-Can still have sex
-Its can insert/remove themselves
-Increased vag discharge normal, if odorous let HCP know

918

Myxedema coma
Cause?
S/S
Treatment

Complication of hypothyroidism

Lethargy, mental sluggishness, eventually coma state

S/S:
Hypothermia
Bradycardia
Hypotension
Decreased MS

Resp distress (low o2, increased resp) prepare for respiratory support (intubate, ventilate)

Other treatment: IVP levothyroxine

919

Hypospadias

Abnormal urethral opening
Under penis

Hourly output monitored post-op

920

Radioactive iodine
First week post-procedure

Treats hyperthyroid
-destroys/damages thyroid
-DELAYED RESPONSE! Takes up to 3 months to work

1 week precautions:
-Continue other meds because of delayed response
-avoid prego's and kids
-no breastfeeding
-no sharing utensils
-no using bare hands to handle other people's food
-isolate laundry/wash separately
-use separate toilet, flush 2-3x after each use
-DRINK FLUIDS
-wash hands thoroughly
-sleep in separate bed
-don't sit near others for a long time (train, flight)

921

Which meds require Liver Enzyme monitoring?

Statins
Isoniazid (for TB)

922

Bowel Irrigation for colostomy

1. fill irrigation container with 500-1000 mL lukewarm water, flush tubing, reclamp, hang on hook or IV pole.
2. Sit on toilet place the irrigation sleeve over the stoma, extend the sleeve into the toilet, and place the irrigation container approximately 18-24 inches above the stoma.
3. Lubricate cone-tipped irrigator, insert cone and attached catheter gently into the stoma, and hold in place
4. Slowly open the roller clamp, allowing irrigation solution to flow for 5-10 minutes
5. Clamp the tubing if cramping occurs, until it subsides
6. Once the desired amount of solution is instilled, the cone is removed and feces is allowed to drain through the sleeve into the toilet

923

Anaphylactic rxn to IV meds

1. stop the infusion
2. ensure airway patency and administer oxygen
3. give epinephrine and initiate IV fluids
4. administer adjunctive therapies (antihistamines, bronchodilators, corticosteroids)
5. Monitor vital sign changes

924

Pulsus Paradoxus

Why?
Cardiac tamponade

Difference between pressure heart at first korotkoff sound during expiration and inspiration.

Difference <10 normal
Difference >10 = cardiac tamponade!

925

Korotkoff sound

Sounds of blood flow during BP evaluation

926

S/S of anaphylaxis

CV:
Vasodilation
-hypotension, edema
Tachycardia

RESP:
Upper airway edema
-stridor, hoarseness
Bronchospasm
-wheezing

CUTANEOUS:
-urticarial rash, pruritus, flushing

GI:
Nausea, vomit, abd pain

Shock:
dizzy, LOC


NOT FEVER

927

Colles Fracture

Distal radius fracture

Wrist fracture
Makes hand/arm look like up-side-down fork